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Who Benefit From Routine Myectomy? "The Role" Of Enucleation With/without Septal Myectomy For Discrete Subaortic Stenosis
Y. Hirata, J. M. Chen, J. M. Quaegebeur, R. S. Mosca. Columbia University, New York, NY,
BACKGROUND:Substantial controversy persists regarding the need and efficacy of a routine myectomy in the treatment of discrete subaortic stenosis. Although some believe myectomy more effectively relieves subaortic narrowing, this is uncertain and complications including heart block and aortic valve injury are concerns. The aims of the study were: 1) to analyze the role of enucleation for relief of subaortic stenosis and the risk factors associated with recurrence and reoperation and 2) to delineate the characteristics of the patients who may benefit from enucleation alone.
METHODS:From January 1990 to May 2007, 221 patients with subaortic stenosis underwent biventricular repair. Of those, 106 patients had discrete subaortic stenosis. The preoperative peak left ventricular outflow tract gradient was 67.3±29mmHg. Forty patients had previous operations for other cardiac anomalies. Median age at repair was 7 years. Sixty one patients underwent isolated enucleation and 45 patients underwent concomitant myectomy. Patients with recurrent subaortic stenosis whose first operation was performed elsewhere were excluded from analysis.
RESULTS:
There was one early death and one late death. The postoperative peak left ventricular outflow gradient decreased to 23.3±22 mmHg (p<0.001). No patient had development of heart block or required a pacemaker. A recurrent gradient greater than 30mmHg was found in 26 patients (27%), 7 patients had reoperations (6.6%). Actuarial freedom from reoperation rates at 5, 10 and 15 years were 95±4.6%, 91±9.0% and 87±13% respectively.
Of those patients who had not undergone a previous cardiac operation, there were no significant differences in the rates of recurrence (28% vs. 27%) or reoperation (4.7% vs. 4.4%) between the enucleation group and the concomitant myectomy group. For the patients who had a previous cardiac operation, the concomitant myectomy group had a significantly lower rate of recurrence; (enucleation 50% vs. enucleation plus myectomy 9%, p=0.0082)
CONCLUSIONS:For those patients undergoing primary operation for discrete subaortic stenosis, routine myectomy does not offer superior relief of left ventricular outflow tract obstruction; enucleation alone provides excellent results in this selected population. However, in those patients who have undergone a previous cardiac operation, concomitant routine myectomy is recommended.
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