The mitral valve and its contribution to the generation of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy: Considerations for surgeons

array:22 ["pii" => "S1134009622000286" "issn" => "11340096" "doi" => "10.1016/j.circv.2022.02.006" "estado" => "S300" "fechaPublicacion" => "2022-10-01" "aid" => "665" "copyrightAnyo" => "2022" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Cir Cardiov. 2022;29 Supl 1:S40-S46" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S1134009622000821" "issn" => "11340096" "doi" => "10.1016/j.circv.2022.02.018" "estado" => "S300" "fechaPublicacion" => "2022-10-01" "aid" => "678" "copyright" => "Sociedad Española de Cirugía Cardiovascular y Endovascular" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Cir Cardiov. 2022;29 Supl 1:S47-S53" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "Revisión" "titulo" => "Reparación robótica de la válvula mitral" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "S47" "paginaFinal" => "S53" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Robotic mitral repair" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1460 "Ancho" => 2500 "Tamanyo" => 229976 ] ] "descripcion" => array:1 [ "es" => "Evolución del tiempo de isquemia miocárdica. La gráfica representa la evolución a lo largo de la serie del tiempo de isquemia miocárdica en pacientes intervenidos de forma consecutiva por insuficiencia mitral degenerativa." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Elena Sandoval, Daniel Pereda" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Elena" "apellidos" => "Sandoval" ] 1 => array:2 [ "nombre" => "Daniel" "apellidos" => "Pereda" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1134009622000821?idApp=UINPBA00004N" "url" => "/11340096/00000029000000S1/v2_202307141006/S1134009622000821/v2_202307141006/es/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S1134009622000808" "issn" => "11340096" "doi" => "10.1016/j.circv.2022.02.016" "estado" => "S300" "fechaPublicacion" => "2022-10-01" "aid" => "676" "copyright" => "Sociedad Española de Cirugía Cardiovascular y Endovascular" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Cir Cardiov. 2022;29 Supl 1:S32-S39" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "Revisión" "titulo" => "Relación entre el volumen quirúrgico y la calidad de la reparación de la insuficiencia mitral severa en centros de referencia" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "S32" "paginaFinal" => "S39" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Relationship between surgical volume and mitral valve repair rates in reference centers" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figura 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2309 "Ancho" => 2500 "Tamanyo" => 537943 ] ] "descripcion" => array:1 [ "es" => "Arriba: comparación entre las curvas de aprendizaje de una especialidad estándar y de una subespecialización quirúrgica con modelo de cocirugía. Abajo: Diagrama de flujo para la transformación de la cirugía mitral en una especialidad, de acuerdo con la literatura actual." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Javier Castillo, Ángel González Pinto" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Javier" "apellidos" => "Castillo" ] 1 => array:2 [ "nombre" => "Ángel" "apellidos" => "González Pinto" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1134009622000808?idApp=UINPBA00004N" "url" => "/11340096/00000029000000S1/v2_202307141006/S1134009622000808/v2_202307141006/es/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Revisión" "titulo" => "The mitral valve and its contribution to the generation of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy: Considerations for surgeons" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "S40" "paginaFinal" => "S46" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Juan B. Grau, Jacqueline H. Fortier" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Juan B." "apellidos" => "Grau" "email" => array:1 [ 0 => "grauju@valleyhealth.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Jacqueline H." "apellidos" => "Fortier" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Cardiothoracic Surgery, The Valley Hospital, Ridgewood, NJ, USA" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Division of Cardiac Surgery, The University of Ottawa Heart Institute, Ottawa, Canada" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La contribución de la válvula mitral a la obstrucción del tracto de salida del ventrículo izquierdo en pacientes con cardiomiopatía hipertrófica: Consideraciones para cirujanos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0035" "etiqueta" => "Fig. 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1057 "Ancho" => 1874 "Tamanyo" => 243664 ] ] "descripcion" => array:1 [ "en" => "Intraoperative images illustrating thickened ectopic chordae inserting into the base of the anterior leaflet of the mitral valve close to anterior trigon (A), ectopic secondary chordae inserting towards the posterior trigone anterior leaflet of the mitral valve B, evidence of tethering effect of secondary chordae encircled by Prolene thread seen side-to-side with normal A2 segment of the anterior leaflet of the mitral valve being lifted by a nerve hook (C), and papillary muscle realignment using a 4–0 Gore-Tex suture tied over pledgets." ] ] ] "textoCompleto" => "IntroductionOne of the first modern descriptions of hypertrophic cardiomyopathy (HCM) was provided by the pathologist Robert Donald Teare, who reported asymmetric cardiac hypertrophy in a case series of autopsies of young adult patients.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> Just two years later, Teare and his colleagues described in more detail the “asymmetrical hypertrophy of the heart, a condition in which the interventricular septum in particular is grossly hypertrophied and bulges into both ventricular cavities.”<a class="elsevierStyleCrossRef" href="#bib0130">2</a> Around this time, several groups were devoting considerable attention to what we now know as HCM. Early explorations of the disease and descriptions of surgical attempts to alleviate left ventricular outflow tract (LVOT) obstruction observed in some patients with HCM have been well documented.<a class="elsevierStyleCrossRefs" href="#bib0135">3,4</a>Given this history, it is not surprising that our understanding of HCM and the surgical approach to treating profoundly symptomatic patients was focused singularly on the hypertrophic septum. Increasingly, however, HCM is understood to be a disease of not just a hypertrophic septum, but of a contributing mitral valve (MV) apparatus. The availability of more modern imaging has demonstrated the MV also plays a very significant role in obstructive forms of HCM.<a class="elsevierStyleCrossRefs" href="#bib0145">5,6</a>The most recent ACC/AHA guidelines for the diagnosis and treatment of HCM acknowledge that approximately three quarters of these patients have a left ventricular outflow tract (LVOT) obstruction, with the mitral valve contributing to the principal mechanisms through which the obstruction is generated.<a class="elsevierStyleCrossRef" href="#bib0155">7</a> In cases where patients have significant LVOT obstruction and persistent, debilitating symptoms despite maximal medical therapy, septal reduction therapy (SRT) is an appropriate treatment. Surgical SRT via septal myectomy is felt to be the appropriate treatment for the widest range of patients.<a class="elsevierStyleCrossRef" href="#bib0155">7</a>The purpose of this paper is to describe the involvement of the MV, subvalvular apparatus and presence of SAM in the generation of LVOT obstruction in patients with HCM, and to make the argument that any surgical management of these patients must, at the very least, evaluate potential MV abnormalities and consider whether they should be addressed. We will describe the presence of MV abnormalities in patients with HCM and discuss the surgical management of HCM patients with symptomatic LVOT obstruction, with a focus on learning from the experience of several major HCM programs around the world. This review of the literature will be contextualized with a description of the clinical journey of an HCM patient treated by one of the authors (JBG).Presence of MV abnormalities in HCMMitral valve abnormalities and SAM are not present in all patients with HCM but are acknowledged elements of the heterogenous HCM phenotype. The ACC/AHA guidelines describe a number of “morphologic abnormalities” that are observed in patients with HCM, including “hypertrophied and apically displaced papillary muscles, … anomalous insertion of the papillary muscle directly in the anterior leaflet of the mitral valve (in the absence of chordae tendinae), [and] elongated mitral valve leaflets.”<a class="elsevierStyleCrossRef" href="#bib0155">7</a> Descriptions in the literature are myriad, and not a recent discovery, with some reports dating back to the late 1960s.<a class="elsevierStyleCrossRefs" href="#bib0145">5,8,9</a> Anteriorly displaced papillary muscles may contact the septum directly during systole, or can create slackness in the mitral valve leaflets, while mid-leaflet and other anomalous insertion of the chordae tendinae can contribute to MV leaflet tenting. All of these conditions, alone or in combination allow the leaflets to be dragged into the left ventricular flow stream.<a class="elsevierStyleCrossRef" href="#bib0145">5</a> Elongated mitral valve leaflets may also result in inadequate coaptation, contributing to both SAM and MR (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Our understanding of the prevalence of MV abnormalities in HCM is growing. Approximately a decade ago, Kown and colleagues described an independent association between abnormal papillary muscles and LVOT obstruction,<a class="elsevierStyleCrossRef" href="#bib0170">10</a> while work by Maron and colleagues described elongated MV leaflets in patients with HCM compared to non-HCM controls.<a class="elsevierStyleCrossRef" href="#bib0175">11</a> In the surgical literature, inconsistent reporting hinders attempts to understand the proportion of patients undergoing septal reduction surgery that also have SAM or other MV abnormalities. One Canadian study reported 50% of HCM patients referred for surgery had significant SAM,<a class="elsevierStyleCrossRef" href="#bib0180">12</a> while a Chinese surgical group observed SAM in all of their surgical patients.<a class="elsevierStyleCrossRef" href="#bib0185">13</a> A series presented by the Cleveland Clinic seemed to indicate a smaller proportion of patients requiring MV intervention, with fewer than 15% of the patients in their series receiving MV procedures at the time of their septal reduction surgery.<a class="elsevierStyleCrossRef" href="#bib0190">14</a>The diversity of MV and subvalvular apparatus anatomy observed in patients with HCM is impressive, as shown in descriptions from high-volume surgical centers performing SRT.<a class="elsevierStyleCrossRefs" href="#bib0145">5,15</a> This phenotypic heterogeneity in MV anatomy in patients with HCM must also be considered in the context of the patient's septal thickness and the ventricular level at which their obstruction is generated (i.e. basal, mid-ventricular or apical). Taken together, these elements help to explain why careful pre-operative planning and a comprehensive diagnostic imaging assessment using modalities such as cardiac magnetic resonance (CMR) and cine computed tomography (CT) are essential. Specifically, the ACC/AHA guidelines note that CMR can “reliably characterize specific features of the LVOT anatomy that may be contributing to SAM-septal contact and obstructive physiology and, therefore, are relevant to strategic planning for septal reduction procedures.”<a class="elsevierStyleCrossRef" href="#bib0155">7</a>Case presentationThe patient was a 32-year-old male presenting with exertional dyspnea and two near syncopal episodes while exercising. He had a family history of HCM; his mother had been diagnosed with what was then called idiopathic hypertrophic subaortic stenosis, now known as HCM, and underwent two septal myectomies in the early 1980s.An initial resting TTE showed evidence of SAM but a resting gradient of only 8mmHg that increased to 22mmHg during Valsalva maneuver (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Given the patient's family history of HCM and his worsening symptoms, he was referred to a cardiologist for more targeted and dynamic investigations. A cardiac MRI demonstrated hypertrophic anterolateral papillary muscle with abnormal insertion, potential evidence of SAM, but no clear gradient through the LVOT. A cine CT demonstrated a septum of 13mm with clear evidence of SAM (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). Dynamic testing was done using treadmill exercise echocardiography, which identified a maximal LVOT gradient during peak exercise was of 313mmHg with evidence of mitral regurgitation (MR). The results of these tests led to the diagnosis of obstructive HCM with severe LVOT gradients during dynamic testing.<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>During his diagnostic workup, which took place over the course of several months, the patients was increasingly symptomatic and reported NYHA class III symptoms despite maximal doses of disopyramide and bisoprolol. After several discussions between the patient and his cardiologist, he was referred for surgery due to failure of medical therapy.Surgical management of HCMIn 1959, a group of British clinicians, including Dr. Teare and the surgeon Dr. W.P. Cleland, published a case report of a surgical treatment of obstructive cardiomyopathy.<a class="elsevierStyleCrossRef" href="#bib0130">2</a> Nevertheless, the name that is most frequently associated with the surgical management of HCM is Dr. Andrew Morrow, for whom the Morrow procedure is named and who was diagnosed with HCM himself.<a class="elsevierStyleCrossRef" href="#bib0200">16</a> The Morrow procedure was the standard surgical approach to treating HCM for many years, and involved a relatively limited resection of muscle from the basal septum.<a class="elsevierStyleCrossRef" href="#bib0200">16</a>Today, surgeons perform an extended septal myectomy, resecting significantly more tissue to better alleviate LVOT obstruction, and many concomitantly address the anomalous chordae tendinae, misaligned papillary muscles and other MV abnormalities. Articles by Affronti et al.<a class="elsevierStyleCrossRef" href="#bib0205">17</a> and Gharibeh et al.<a class="elsevierStyleCrossRef" href="#bib0210">18</a> provide significant detail and context about the various approaches and techniques used to address the diversity of MV abnormalities seen in patients with HCM for the interested reader. As well, Kotkar and colleagues provides excellent illustrations of the diverse phenotypes they have observed in their HCM surgical program.<a class="elsevierStyleCrossRef" href="#bib0195">15</a>It must be noted that although MV abnormalities are well described as a component of the HCM phenotype,<a class="elsevierStyleCrossRef" href="#bib0155">7</a> there is some controversy about the necessity of concomitant procedures of the MV and subvalvular apparatus during septal reduction surgery. The Mayo clinic has described their extensive experience with the surgical management of HCM, including descriptions of diverse MV anomalies,<a class="elsevierStyleCrossRef" href="#bib0195">15</a> but their approach is generally to use septal myectomy alone to treat LVOT obstruction<a class="elsevierStyleCrossRef" href="#bib0215">19</a> and suggest that this approach is sufficient for almost all patients.<a class="elsevierStyleCrossRef" href="#bib0220">20</a> The surgical program at Toronto General Hospital, one of the primary referral centers in Canada, has published the results of their experience using isolated septal myectomy to treat HCM with good results.<a class="elsevierStyleCrossRef" href="#bib0180">12</a>This approach contrasts with other centers that more routinely address MV anomalies during SRT. A recent series by clinicians from Milan report that approximately half of HCM patients undergoing SRT required mitral valve intervention. They reported that addressing the MV apparatus may be more important when patients do not have a particularly thick septum.<a class="elsevierStyleCrossRef" href="#bib0225">21</a> The Cleveland Clinic similarly reports MV interventions in approximately a third of their SRT procedures for HCM, and also noted the importance of addressing the MV in patients with thin septae.<a class="elsevierStyleCrossRef" href="#bib0230">22</a> A report from Oregon is perhaps even more pronounced in its support of addressing MV anomalies; Song and colleagues describe routine papillary muscle realignment in a cohort of patients undergoing SRT, with very good results.<a class="elsevierStyleCrossRef" href="#bib0235">23</a>At present there is no definitive consensus about whether addressing the MV apparatus is essential for alleviating LVOT obstruction. The guidelines clearly reflect this controversy, advising “transaortic extended septal myectomy” for patients with obstructive HCM who experience debilitating symptoms, but note that “some centers achieve these results with isolated extended septal myectomy, [while] other centers have found value in including revision of the anterior mitral leaflet or apparatus.”<a class="elsevierStyleCrossRef" href="#bib0155">7</a>Case presentationThe patient underwent a transesophageal echocardiogram (TEE) after the induction of anesthesia to evaluate the LVOT gradient and mechanism of obstruction. Under resting conditions, the TEE demonstrated a 13mm septum, hypertrophic anterior lateral papillary muscle group, SAM without associated mitral insufficiency, and a peak gradient of 30mmHg. A gradient was provoked with isoproterenol drip and nitroglycerine; in these conditions, the patient's LVOT gradient increased to 283mmHg with torrential MR (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).<elsevierMultimedia ident="fig0025"></elsevierMultimedia>The patient underwent an extended septal myectomy, with the resection of a segment approximately 30mm by 35mm by 7mm at the level of the septum (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>). Seven abnormal secondary chordae were resected (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>A–C) followed by a realignment of the anterior lateral papillary muscle group towards the posterior medial papillary muscle group using a 4–0 Gore-Tex pledgeted suture (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>D). Abnormal muscular connections between the septum and the base of the anterolateral papillary muscle group were resected allowing full mobility of the anterolateral papillary muscle group that was abnormally inserted.<elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia>The post-procedural TEE demonstrated normal coaptation between the anterior and posterior leaflets of the mitral valve, with a coaptation point significantly displaced towards the posterior annulus (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>). There was no evidence of SAM, and trace mitral insufficiency. Under maximal provocation the peak gradient through the LVOT was 18mmHg with a mean of 9mmHg. The patient had an uneventful postoperative course in hospital, and was discharged home on post-operative day 4.<elsevierMultimedia ident="fig0040"></elsevierMultimedia>DiscussionOur understanding of HCM has evolved over the past several decades, and the contributions of the MV and subvalvular apparatus to the generation of LVOT obstruction is now well understood. Myriad and diverse MV anomalies are accepted as part of the HCM phenotype, and these must be considered when diagnosing and managing this complex disease.While there is some controversy about the necessity of addressing the MV during SRT, many surgeons see it as an essential tool to eliminate SAM and alleviate obstruction. The results of some experienced surgeons in high volume centers suggest that good alleviation of LVOT obstruction can be achieved through an isolated septal myectomy. However, the literature increasingly reflects a wider adoption of a variety of techniques to address the MV and apparatus with very good short- and mid-term results. Many reports in the literature consistently suggest that addressing MV anomalies has led to the reliable elimination of SAM and reduction of LVOT obstructions under both resting and dynamic conditions.There is another potential consequence of a pointed focus on septal thickness and isolated myectomy to treat obstructive HCM, and that is the potential exclusion of patients without significant septal hypertrophy from consideration for SRT. Our case presentation was carefully chosen, highlighting the profound dynamic obstruction and disabling symptoms that can be observed in an HCM patient with a relatively thin septum. This young patient had been monitored for HCM due to his family history, but the absence of a grossly hypertrophic septum resulted in his symptoms of exertional dyspnea being mis-diagnosed as exercise-induced asthma for many years. After careful investigation by a cardiologist with expertise in cardiac MR and an interest in HCM, his profound dynamic obstruction was diagnosed. Interestingly, this patient was discouraged from pursuing SRT at a large center that limits its practice to isolated septal myectomy, as they did not feel confident that surgical intervention would improve this patient's symptoms or quality of life. This patient experienced profound improvement in his symptoms following an extended septal myectomy with resection of anomalous chordae and realignment of his anterior lateral papillary muscles. He has resumed regular activities, including travel, a busy work life and exercise. It is important for clinicians to carefully consider the diverse mechanisms through which LVOT obstruction can be generated in patients with HCM, and surgeons should be strongly encouraged to tailor their operation to the individual phenotype of each patient they bring to the OR.One other potential consideration when evaluating whether or not to integrate concomitant MV and apparatus procedures as part of the standard SRT is to consider if they might lend themselves to simplified or safer procedure with an easier learning curve. The scarcity of septal myectomy surgeons has been acknowledged for many years.<a class="elsevierStyleCrossRef" href="#bib0240">24</a> The current supply in most countries is insufficient, and many skilled myectomy surgeons are well into the latter years of their career. Training the next generation of surgeons to perform SRT on patients with HCM is essential, but the challenges and risks of the procedure make that training difficult. In some ways, surgical treatment of HCM today is similar to mitral valve repair twenty years ago, with a variety of centers extolling the virtues of a diversity of techniques to treat a condition that is relatively common and afflicting a comparatively young patient population. Modern MV repair is a safe and widely-available procedure, and while there is still some variability in technique, the preference has shifted away from leaflet resection and towards the use of Gore-Tex neochordae. We would suggest that one reason for this is the ability to adjust or reverse the repair if needed; once tissue is resected, there is no way back. Some techniques that address MV anomalies, including realignment of papillary muscles using a pledgeted Gore-Tex suture, also offer reversibility in case an adjustment is required. One experienced myectomy surgeon reported that incorporating papillary muscle realignment into his SRT procedures reduced the need for more complicated MV techniques.<a class="elsevierStyleCrossRef" href="#bib0235">23</a> It is worth exploring whether some of these techniques might prove beneficial to surgeons during their learning curve, to better ensure the elimination of SAM and LVOT obstruction in cases where a dramatic resection of septal tissue is either not possible or poses an unacceptable risk of creating an iatrogenic ventral septal defect (VSD). Given the urgent need to train more surgeons in these techniques, no avenue should go unexplored. If realigning papillary muscles or resecting anomalous chordae help a larger number of surgeons to safely and adequately address LVOT obstruction in patients with HCM, certainly these techniques should be considered for wider adoption.When I (JBG) was first operating on patients with HCM, I identified a need to protocolize the operation in order to ensure success. I did not have the benefit of a fellowship in SRT, I had the benefit of strong support from the HCM cardiologist at my institution, who provided comprehensive support and extremely thorough diagnostic imaging. The majority of my patients presented without severely hypertrophic septae, and most had clear MV anomalies that were contributing to LVOT obstruction. I devised a protocol for myself to approach each operation. I began by resecting septal tissue to address that component of LVOT obstruction, and to increase visibility into the ventricle. Then I assess and resect any anomalous chordae. Lastly, I perform a realignment of the anterolateral papillary muscles. This approach is tailored to each patient, but I have found it to deliver consistent results for my patients, and would suggest that approaching this very complex surgery in a clear, linear manner helped to reduce my learning curve and allowed me to provide even my earliest patients with excellent results. Let me note, however, that SRT is not an operation to be undertaken lightly. I suspect that one of the reasons that there is a paucity of surgeons performing SRT is the potential for a single mistake to create catastrophic problems in a patient population that is often relatively young; nobody wants to be responsible for a massive VSD or complete heart block in a 35 year old patient.Finally, we would respectfully advocate that those surgeons with the benefit of experience and a long history of successful cases should take steps to report their results more uniformly. The reporting of MV anomalies, SAM and MR is inconsistent and oftentimes missing from surgical case series in the literature, which makes it difficult or impossible to compare patient populations and outcomes between centers with different surgical approaches. If we are to move SRT from select high-volume centers to become a more widely-available technique, we must share data, compare outcomes, and work collaboratively to identify which techniques can be broadly adopted and easily taught to the next generation of myectomy surgeons. Too many patients find themselves desperately in need of SRT, but with few or no experienced surgeons in their city or even their country to perform this life-changing operation. HCM centers of all types should make a concerted effort to more clearly, consistently and transparently report their experiences, to the benefit of all.Patients with HCM present with a diverse array of MV anomalies, many of which contribute to LVOT obstruction. While support for concomitant MV procedures during surgical myectomy is not universal, there is strong support in the literature for excellent, durable results when these procedures are undertaken.Ethical disclosuresThe description of the case example in the article has been written in a way to not identify the patient, and the patient provided written permission for his case example to be used.FundingThe authors acknowledge the generous support of the Cannstatter Foundation, Inc.Conflict of interestThe authors declare they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1930438" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1663994" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1930437" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1663995" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Presence of MV abnormalities in HCM" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Case presentation" ] ] ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Surgical management of HCM" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Case presentation" ] ] ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 11 => array:2 [ "identificador" => "xack675913" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-01-30" "fechaAceptado" => "2022-02-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1663994" "palabras" => array:2 [ 0 => "Hypertrophic cardiomyopathy" 1 => "Mitral valve" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1663995" "palabras" => array:2 [ 0 => "Miocardiopatía hipertrófica" 1 => "Valvula mitral" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Hypertrophic cardiomyopathy is increasingly understood to be a disease that presents not only with septal hypertrophy but also with diverse anomalies of the mitral valve and subvalvular apparatus. In this review, we describe the involvement of the mitral valve in the generation of left ventricular outflow tract obstruction in patients with hypertrophic cardiomyopathy, and discuss the surgical approaches to managing this complex condition." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La cardiomiopatía hipertrófica está cada vez más entendida como una enfermedad que se presenta no solo con evidencia de hipertrofia septal, sino también con diversas anormalidades de la válvula mitral y su aparato subvalvular. En este artículo describimos la contribución de la válvula mitral a la generación de la obstrucción del tracto de salida del ventrículo izquierdo en pacientes con cardiomiopatía hipertrófica obstructiva, además de discutir los diferentes abordajes quirúrgicos disponibles para tratar esta compleja patología." ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 591 "Ancho" => 1874 "Tamanyo" => 79820 ] ] "descripcion" => array:1 [ "en" => "Illustration of normal mitral leaflet coaptation and orientation of papillary muscles axis towards center of mitral valve allowing normal flow through LVOT (A) in contrast to turbulent flow through LVOT caused by abnormal orientation of hypertrophic anterolateral papillary muscle, the presence of a mildly hypertophic sigmoid septum, and secondary ectopic chordae tethering and bending the anterior leaflet of the mitral valve causing a hockey stick deformity." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1376 "Ancho" => 1874 "Tamanyo" => 199320 ] ] "descripcion" => array:1 [ "en" => "A normal papillary muscle anatomy and coaptation between anterior and posterior leaflet of mitral valve with wide aorto ventricular angle (left) contrasts markedly with an abnormal anteriolateral papillary muscle group with it axis oriented towards the aortic valve instead of mitral valve (right)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1278 "Ancho" => 1674 "Tamanyo" => 157236 ] ] "descripcion" => array:1 [ "en" => "Resting Doppler echocardiogram with no evidence of MR or severe LOVOT obstruction." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1200 "Ancho" => 1207 "Tamanyo" => 98337 ] ] "descripcion" => array:1 [ "en" => "Cine CT demonstrating systolic anterior motion of the mitral valve in the setting of a thin septum." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 484 "Ancho" => 1874 "Tamanyo" => 111749 ] ] "descripcion" => array:1 [ "en" => "Intraoperative transesophageal echocardiogram showing the presence of systolic anterior motion of the mitral valve (A), Doppler waveform with SAM but no mitral regurgitation (B), and a severe LVOT gradient with mitral regurgitation after the administration of isoproterenol, dobutamine and nitroglycerine (C)." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1205 "Ancho" => 905 "Tamanyo" => 266693 ] ] "descripcion" => array:1 [ "en" => "Surgical specimen consisting of resected septal tissue and anomalous chordae." ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Fig. 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1057 "Ancho" => 1874 "Tamanyo" => 243664 ] ] "descripcion" => array:1 [ "en" => "Intraoperative images illustrating thickened ectopic chordae inserting into the base of the anterior leaflet of the mitral valve close to anterior trigon (A), ectopic secondary chordae inserting towards the posterior trigone anterior leaflet of the mitral valve B, evidence of tethering effect of secondary chordae encircled by Prolene thread seen side-to-side with normal A2 segment of the anterior leaflet of the mitral valve being lifted by a nerve hook (C), and papillary muscle realignment using a 4–0 Gore-Tex suture tied over pledgets." ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Fig. 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 582 "Ancho" => 1874 "Tamanyo" => 144243 ] ] "descripcion" => array:1 [ "en" => "Post-procedural transesophageal echocardiogram demonstrating coaptation of the anterior and posterior leaflets of the mitral valve displaced towards the posterior annulus (A); trace mitral regurgitation during provocation with isoproterenol, dobutamine and nitroglycerine (B); and peak and mean gradients under maximal provocation (C)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Asymmetrical hypertrophy of the heart in young adults" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D. Teare" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/hrt.20.1.1" "Revista" => array:6 [ "tituloSerie" => "Br Heart J" "fecha" => "1958" "volumen" => "20" "paginaInicial" => "1" "paginaFinal" => "8" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13499764" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0130" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Obstructive cardiomyopathy simulating aortic stenosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.F. Goodwin" 1 => "A. Hollman" 2 => "W.P. Cleland" 3 => "D. Teare" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/hrt.22.3.403" "Revista" => array:6 [ "tituloSerie" => "Br Heart J" "fecha" => "1960" "volumen" => "22" "paginaInicial" => "403" "paginaFinal" => "414" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13851098" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0135" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "From Teare to the present day: a fifty year odyssey in hypertrophic cardiomyopathy, a paradigm for the logic of the discovery process" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "W.J. McKenna" 1 => "S. Sen-Chowdhry" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s1885-5857(09)60050-5" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Cardiol" "fecha" => "2008" "volumen" => "61" "paginaInicial" => "1239" "paginaFinal" => "1244" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19080961" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0140" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Contemporary treatment of hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.J. Marian" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Tex Heart Inst J" "fecha" => "2009" "volumen" => "36" "paginaInicial" => "194" "paginaFinal" => "204" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19568388" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0145" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The mitral valve in obstructive hypertrophic cardiomyopathy: a test in context" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.V. Sherrid" 1 => "S. Balaram" 2 => "B. Kim" 3 => "L. Axel" 4 => "D.G. Swistel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2016.01.071" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2016" "volumen" => "67" "paginaInicial" => "1846" "paginaFinal" => "1858" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27081025" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0150" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The mitral valve in hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Woo" 1 => "S. Jedrzkiewicz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.111.035568" "Revista" => array:7 [ "tituloSerie" => "Circulation" "fecha" => "2011" "volumen" => "124" "paginaInicial" => "9" "paginaFinal" => "12" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21730319" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1201971215001174" "estado" => "S300" "issn" => "12019712" ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0155" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.R. Ommen" 1 => "S. Mital" 2 => "M.A. Burke" 3 => "S.M. Day" 4 => "A. Deswal" 5 => "P. Elliott" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIR.0000000000000937" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2020" "volumen" => "142" "paginaInicial" => "e558" "paginaFinal" => "e631" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33215931" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0160" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anomalous insertion of papillary muscle directly into anterior mitral leaflet in hypertrophic cardiomyopathy. Significance in producing left ventricular outflow obstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H.G. Klues" 1 => "W.C. Roberts" 2 => "B.J. Maron" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/01.cir.84.3.1188" "Revista" => array:7 [ "tituloSerie" => "Circulation" "fecha" => "1991" "volumen" => "84" "paginaInicial" => "1188" "paginaFinal" => "1197" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1884449" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0303846714001590" "estado" => "S300" "issn" => "03038467" ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0165" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diversity of structural mitral valve alterations in hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H.G. Klues" 1 => "B.J. Maron" 2 => "A.L. Dollar" 3 => "W.C. Roberts" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/01.cir.85.5.1651" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "1992" "volumen" => "85" "paginaInicial" => "1651" "paginaFinal" => "1660" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1572023" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0170" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Abnormal papillary muscle morphology is independently associated with increased left ventricular outflow tract obstruction in hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.H. Kwon" 1 => "R.M. Setser" 2 => "M. Thamilarasan" 3 => "Z.V. Popovic" 4 => "N.G. Smedira" 5 => "P. Schoenhagen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/hrt.2007.118018" "Revista" => array:6 [ "tituloSerie" => "Heart" "fecha" => "2008" "volumen" => "94" "paginaInicial" => "1295" "paginaFinal" => "1301" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17690158" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0175" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve abnormalities identified by cardiovascular magnetic resonance represent a primary phenotypic expression of hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.S. Maron" 1 => "I. Olivotto" 2 => "C. Harrigan" 3 => "E. Appelbaum" 4 => "C.M. Gibson" 5 => "J.R. Lesser" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.110.985812" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2011" "volumen" => "124" "paginaInicial" => "40" "paginaFinal" => "47" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21670234" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0180" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Isolated septal myectomy for hypertrophic obstructive cardiomyopathy: an update on the Toronto General Hospital experience" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.D. Vanderlaan" 1 => "A. Woo" 2 => "A. Ralph-Edwards" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Ann Cardiothorac Surg" "fecha" => "2017" "volumen" => "6" "paginaInicial" => "364" "paginaFinal" => "368" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0185" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The surgical management of hypertrophic obstructive cardiomyopathy with the concomitant mitral valve abnormalities" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Cui" 1 => "S. Wang" 2 => "J. Xu" 3 => "W. Wang" 4 => "Y. Song" 5 => "H. Sun" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/icvts/ivv257" "Revista" => array:6 [ "tituloSerie" => "Interact Cardiovasc Thorac Surg" "fecha" => "2015" "volumen" => "21" "paginaInicial" => "722" "paginaFinal" => "726" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26374266" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0190" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mitral valve abnormalities in hypertrophic cardiomyopathy: echocardiographic features and surgical outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.K. Kaple" 1 => "R.T. Murphy" 2 => "L.M. DiPaola" 3 => "P.L. Houghtaling" 4 => "H.M. Lever" 5 => "B.W. Lytle" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2008.01.061" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2008" "volumen" => "85" "paginaInicial" => "1527" "paginaFinal" => "1535" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18442532" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0195" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hypertrophic obstructive cardiomyopathy: the Mayo Clinic experience" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K.D. Kotkar" 1 => "S.M. Said" 2 => "J.A. Dearani" 3 => "H.V. Schaff" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.21037/acs.2017.07.03" "Revista" => array:6 [ "tituloSerie" => "Ann Cardiothorac Surg" "fecha" => "2017" "volumen" => "6" "paginaInicial" => "329" "paginaFinal" => "336" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28944173" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0200" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The father of septal myectomy for obstructive HCM, who also had HCM: the unbelievable story" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B.J. Maron" 1 => "W.C. Roberts" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2016.05.002" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2016" "volumen" => "67" "paginaInicial" => "2900" "paginaFinal" => "2903" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27311529" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0205" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgery for hypertrophic obstructive cardiomyopathy: comprehensive LVOT management beyond septal myectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Affronti" 1 => "R. Pruna-Guillen" 2 => "E. Sandoval" 3 => "D. Pereda" 4 => "J. Alcocer" 5 => "M. Castellà" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "J Clin Med" "fecha" => "2021" "volumen" => "10" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0210" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comprehensive left ventricular outflow tract management beyond septal reduction to relieve obstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Gharibeh" 1 => "N.G. Smedira" 2 => "J.B. Grau" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Asian Cardiovasc Thorac Ann" "fecha" => "2021" "itemHostRev" => array:3 [ "pii" => "S1529943016311287" "estado" => "S300" "issn" => "15299430" ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0215" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of the mitral valve in patients with obstructive hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.H. Hong" 1 => "A. Nguyen" 2 => "H.V. Schaff" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s12055-019-00817-y" "Revista" => array:7 [ "tituloSerie" => "Indian J Thorac Cardiovasc Surg" "fecha" => "2020" "volumen" => "36" "numero" => "Suppl. 1" "paginaInicial" => "34" "paginaFinal" => "43" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33061183" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0220" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is anterior mitral valve leaflet length important in outcome of septal myectomy for obstructive hypertrophic cardiomyopathy?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Lentz Carvalho" 1 => "H.V. Schaff" 2 => "R.A. Nishimura" 3 => "S.R. Ommen" 4 => "J.B. Geske" 5 => "B.D. Lahr" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "2021" ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0225" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hypertrophic cardiomyopathy with moderate septal thickness and mitral regurgitation: long-term surgical results" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Lapenna" 1 => "T. Nisi" 2 => "D. Carino" 3 => "M. Bargagna" 4 => "S. Ruggeri" 5 => "E. Zancanaro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ejcts/ezab097" "Revista" => array:6 [ "tituloSerie" => "Eur J Cardiothorac Surg" "fecha" => "2021" "volumen" => "60" "paginaInicial" => "244" "paginaFinal" => "251" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33624799" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0230" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical management of left ventricular outflow tract obstruction in a specialized hypertrophic obstructive cardiomyopathy center" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K. Hodges" 1 => "C.G. Rivas" 2 => "J. Aguilera" 3 => "R. Borden" 4 => "A. Alashi" 5 => "E.H. Blackstone" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jtcvs.2018.11.148" "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "2019" "volumen" => "157" "paginaInicial" => "2289" "paginaFinal" => "2299" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30782406" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0235" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Routine papillary muscle realignment and septal myectomy for obstructive hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H.K. Song" 1 => "J. Turner" 2 => "R. Macfie" 3 => "S. Kumar" 4 => "M.J. Mannello" 5 => "D. Smith" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2018.04.026" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2018" "volumen" => "106" "paginaInicial" => "670" "paginaFinal" => "675" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29753818" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0240" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Why we need more septal myectomy surgeons: an emerging recognition" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.J. Maron" 1 => "J.A. Dearani" 2 => "M.S. Maron" 3 => "S.R. Ommen" 4 => "H. Rastegar" 5 => "R.A. Nishimura" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jtcvs.2016.12.038" "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "2017" "volumen" => "154" "paginaInicial" => "1681" "paginaFinal" => "1685" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28268009" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack675913" "titulo" => "Acknowledgements" "texto" => "The authors wish to acknowledge the generous support of the Canstatter Foundation, Inc. We also wish to express our thanks to Paloma Segura Amoros for her illustrations, and to the patient described in this article, who provided permission for details of his case to be used." "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/11340096/00000029000000S1/v2_202307141006/S1134009622000286/v2_202307141006/en/main.assets" "Apartado" => array:4 [ "identificador" => "94680" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Revisiones" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/11340096/00000029000000S1/v2_202307141006/S1134009622000286/v2_202307141006/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1134009622000286?idApp=UINPBA00004N"]

Statistics

Revisión

La contribución de la válvula mitral a la obstrucción del tracto de salida del ventrículo izquierdo en pacientes con cardiomiopatía hipertrófica: Consideraciones para cirujanos

Juan B. Graua,b,

Corresponding author

grauju@valleyhealth.com

Corresponding author.

, Jacqueline H. Fortiera

a Department of Cardiothoracic Surgery, The Valley Hospital, Ridgewood, NJ, USA

b Division of Cardiac Surgery, The University of Ottawa Heart Institute, Ottawa, Canada

Read

1457

Times
was read the article

329

Total PDF

1128

Total HTML

Share statistics

 array:22 [
  "pii" => "S1134009622000286"
  "issn" => "11340096"
  "doi" => "10.1016/j.circv.2022.02.006"
  "estado" => "S300"
  "fechaPublicacion" => "2022-10-01"
  "aid" => "665"
  "copyrightAnyo" => "2022"
  "documento" => "article"
  "crossmark" => 1
  "subdocumento" => "fla"
  "cita" => "Cir Cardiov. 2022;29 Supl 1:S40-S46"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:1 [
    "total" => 0
  ]
  "itemSiguiente" => array:18 [
    "pii" => "S1134009622000821"
    "issn" => "11340096"
    "doi" => "10.1016/j.circv.2022.02.018"
    "estado" => "S300"
    "fechaPublicacion" => "2022-10-01"
    "aid" => "678"
    "copyright" => "Sociedad Espa&#241;ola de Cirug&#237;a Cardiovascular y Endovascular"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Cir Cardiov. 2022;29 Supl 1:S47-S53"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:1 [
      "total" => 0
    ]
    "es" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Revisi&#243;n</span>"
      "titulo" => "Reparaci&#243;n rob&#243;tica de la v&#225;lvula mitral"
      "tienePdf" => "es"
      "tieneTextoCompleto" => "es"
      "tieneResumen" => array:2 [
        0 => "es"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "S47"
          "paginaFinal" => "S53"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "en" => array:1 [
          "titulo" => "Robotic mitral repair"
        ]
      ]
      "contieneResumen" => array:2 [
        "es" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "es" => true
      ]
      "contienePdf" => array:1 [
        "es" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0015"
          "etiqueta" => "Figura 3"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr3.jpeg"
              "Alto" => 1460
              "Ancho" => 2500
              "Tamanyo" => 229976
            ]
          ]
          "descripcion" => array:1 [
            "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evoluci&#243;n del tiempo de isquemia mioc&#225;rdica&#46; La gr&#225;fica representa la evoluci&#243;n a lo largo de la serie del tiempo de isquemia mioc&#225;rdica en pacientes intervenidos de forma consecutiva por insuficiencia mitral degenerativa&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Elena Sandoval, Daniel Pereda"
          "autores" => array:2 [
            0 => array:2 [
              "nombre" => "Elena"
              "apellidos" => "Sandoval"
            ]
            1 => array:2 [
              "nombre" => "Daniel"
              "apellidos" => "Pereda"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "es"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1134009622000821?idApp=UINPBA00004N"
    "url" => "/11340096/00000029000000S1/v2_202307141006/S1134009622000821/v2_202307141006/es/main.assets"
  ]
  "itemAnterior" => array:18 [
    "pii" => "S1134009622000808"
    "issn" => "11340096"
    "doi" => "10.1016/j.circv.2022.02.016"
    "estado" => "S300"
    "fechaPublicacion" => "2022-10-01"
    "aid" => "676"
    "copyright" => "Sociedad Espa&#241;ola de Cirug&#237;a Cardiovascular y Endovascular"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Cir Cardiov. 2022;29 Supl 1:S32-S39"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:1 [
      "total" => 0
    ]
    "es" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Revisi&#243;n</span>"
      "titulo" => "Relaci&#243;n entre el volumen quir&#250;rgico y la calidad de la reparaci&#243;n de la insuficiencia mitral severa en centros de referencia"
      "tienePdf" => "es"
      "tieneTextoCompleto" => "es"
      "tieneResumen" => array:2 [
        0 => "es"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "S32"
          "paginaFinal" => "S39"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "en" => array:1 [
          "titulo" => "Relationship between surgical volume and mitral valve repair rates in reference centers"
        ]
      ]
      "contieneResumen" => array:2 [
        "es" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "es" => true
      ]
      "contienePdf" => array:1 [
        "es" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0020"
          "etiqueta" => "Figura 4"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr4.jpeg"
              "Alto" => 2309
              "Ancho" => 2500
              "Tamanyo" => 537943
            ]
          ]
          "descripcion" => array:1 [
            "es" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Arriba&#58; comparaci&#243;n entre las curvas de aprendizaje de una especialidad est&#225;ndar y de una subespecializaci&#243;n quir&#250;rgica con modelo de cocirug&#237;a&#46; Abajo&#58; Diagrama de flujo para la transformaci&#243;n de la cirug&#237;a mitral en una especialidad&#44; de acuerdo con la literatura actual&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Javier Castillo, &#193;ngel Gonz&#225;lez Pinto"
          "autores" => array:2 [
            0 => array:2 [
              "nombre" => "Javier"
              "apellidos" => "Castillo"
            ]
            1 => array:2 [
              "nombre" => "&#193;ngel"
              "apellidos" => "Gonz&#225;lez Pinto"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "es"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1134009622000808?idApp=UINPBA00004N"
    "url" => "/11340096/00000029000000S1/v2_202307141006/S1134009622000808/v2_202307141006/es/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Revisi&#243;n</span>"
    "titulo" => "The mitral valve and its contribution to the generation of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy&#58; Considerations for surgeons"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "S40"
        "paginaFinal" => "S46"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Juan B&#46; Grau, Jacqueline H&#46; Fortier"
        "autores" => array:2 [
          0 => array:4 [
            "nombre" => "Juan B&#46;"
            "apellidos" => "Grau"
            "email" => array:1 [
              0 => "grauju@valleyhealth.com"
            ]
            "referencia" => array:3 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              2 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Jacqueline H&#46;"
            "apellidos" => "Fortier"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "Department of Cardiothoracic Surgery&#44; The Valley Hospital&#44; Ridgewood&#44; NJ&#44; USA"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Division of Cardiac Surgery&#44; The University of Ottawa Heart Institute&#44; Ottawa&#44; Canada"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "La contribuci&#243;n de la v&#225;lvula mitral a la obstrucci&#243;n del tracto de salida del ventr&#237;culo izquierdo en pacientes con cardiomiopat&#237;a hipertr&#243;fica&#58; Consideraciones para cirujanos"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0035"
        "etiqueta" => "Fig&#46; 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
            "Alto" => 1057
            "Ancho" => 1874
            "Tamanyo" => 243664
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Intraoperative images illustrating thickened ectopic chordae inserting into the base of the anterior leaflet of the mitral valve close to anterior trigon &#40;A&#41;&#44; ectopic secondary chordae inserting towards the posterior trigone anterior leaflet of the mitral valve B&#44; evidence of tethering effect of secondary chordae encircled by Prolene thread seen side-to-side with normal A2 segment of the anterior leaflet of the mitral valve being lifted by a nerve hook &#40;C&#41;&#44; and papillary muscle realignment using a 4&#8211;0 Gore-Tex suture tied over pledgets&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">One of the first modern descriptions of hypertrophic cardiomyopathy &#40;HCM&#41; was provided by the pathologist Robert Donald Teare&#44; who reported asymmetric cardiac hypertrophy in a case series of autopsies of young adult patients&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> Just two years later&#44; Teare and his colleagues described in more detail the &#8220;asymmetrical hypertrophy of the heart&#44; a condition in which the interventricular septum in particular is grossly hypertrophied and bulges into both ventricular cavities&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a> Around this time&#44; several groups were devoting considerable attention to what we now know as HCM&#46; Early explorations of the disease and descriptions of surgical attempts to alleviate left ventricular outflow tract &#40;LVOT&#41; obstruction observed in some patients with HCM have been well documented&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Given this history&#44; it is not surprising that our understanding of HCM and the surgical approach to treating profoundly symptomatic patients was focused singularly on the hypertrophic septum&#46; Increasingly&#44; however&#44; HCM is understood to be a disease of not just a hypertrophic septum&#44; but of a contributing mitral valve &#40;MV&#41; apparatus&#46; The availability of more modern imaging has demonstrated the MV also plays a very significant role in obstructive forms of HCM&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The most recent ACC&#47;AHA guidelines for the diagnosis and treatment of HCM acknowledge that approximately three quarters of these patients have a left ventricular outflow tract &#40;LVOT&#41; obstruction&#44; with the mitral valve contributing to the principal mechanisms through which the obstruction is generated&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a> In cases where patients have significant LVOT obstruction and persistent&#44; debilitating symptoms despite maximal medical therapy&#44; septal reduction therapy &#40;SRT&#41; is an appropriate treatment&#46; Surgical SRT via septal myectomy is felt to be the appropriate treatment for the widest range of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The purpose of this paper is to describe the involvement of the MV&#44; subvalvular apparatus and presence of SAM in the generation of LVOT obstruction in patients with HCM&#44; and to make the argument that any surgical management of these patients must&#44; at the very least&#44; evaluate potential MV abnormalities and consider whether they should be addressed&#46; We will describe the presence of MV abnormalities in patients with HCM and discuss the surgical management of HCM patients with symptomatic LVOT obstruction&#44; with a focus on learning from the experience of several major HCM programs around the world&#46; This review of the literature will be contextualized with a description of the clinical journey of an HCM patient treated by one of the authors &#40;JBG&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Presence of MV abnormalities in HCM</span><p id="par0025" class="elsevierStylePara elsevierViewall">Mitral valve abnormalities and SAM are not present in all patients with HCM but are acknowledged elements of the heterogenous HCM phenotype&#46; The ACC&#47;AHA guidelines describe a number of &#8220;morphologic abnormalities&#8221; that are observed in patients with HCM&#44; including &#8220;hypertrophied and apically displaced papillary muscles&#44; &#8230; anomalous insertion of the papillary muscle directly in the anterior leaflet of the mitral valve &#40;in the absence of chordae tendinae&#41;&#44; &#91;and&#93; elongated mitral valve leaflets&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a> Descriptions in the literature are myriad&#44; and not a recent discovery&#44; with some reports dating back to the late 1960s&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">5&#44;8&#44;9</span></a> Anteriorly displaced papillary muscles may contact the septum directly during systole&#44; or can create slackness in the mitral valve leaflets&#44; while mid-leaflet and other anomalous insertion of the chordae tendinae can contribute to MV leaflet tenting&#46; All of these conditions&#44; alone or in combination allow the leaflets to be dragged into the left ventricular flow stream&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a> Elongated mitral valve leaflets may also result in inadequate coaptation&#44; contributing to both SAM and MR &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Our understanding of the prevalence of MV abnormalities in HCM is growing&#46; Approximately a decade ago&#44; Kown and colleagues described an independent association between abnormal papillary muscles and LVOT obstruction&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> while work by Maron and colleagues described elongated MV leaflets in patients with HCM compared to non-HCM controls&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a> In the surgical literature&#44; inconsistent reporting hinders attempts to understand the proportion of patients undergoing septal reduction surgery that also have SAM or other MV abnormalities&#46; One Canadian study reported 50&#37; of HCM patients referred for surgery had significant SAM&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> while a Chinese surgical group observed SAM in all of their surgical patients&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> A series presented by the Cleveland Clinic seemed to indicate a smaller proportion of patients requiring MV intervention&#44; with fewer than 15&#37; of the patients in their series receiving MV procedures at the time of their septal reduction surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The diversity of MV and subvalvular apparatus anatomy observed in patients with HCM is impressive&#44; as shown in descriptions from high-volume surgical centers performing SRT&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">5&#44;15</span></a> This phenotypic heterogeneity in MV anatomy in patients with HCM must also be considered in the context of the patient&#39;s septal thickness and the ventricular level at which their obstruction is generated &#40;i&#46;e&#46; basal&#44; mid-ventricular or apical&#41;&#46; Taken together&#44; these elements help to explain why careful pre-operative planning and a comprehensive diagnostic imaging assessment using modalities such as cardiac magnetic resonance &#40;CMR&#41; and cine computed tomography &#40;CT&#41; are essential&#46; Specifically&#44; the ACC&#47;AHA guidelines note that CMR can &#8220;reliably characterize specific features of the LVOT anatomy that may be contributing to SAM-septal contact and obstructive physiology and&#44; therefore&#44; are relevant to strategic planning for septal reduction procedures&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a></p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case presentation</span><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was a 32-year-old male presenting with exertional dyspnea and two near syncopal episodes while exercising&#46; He had a family history of HCM&#59; his mother had been diagnosed with what was then called idiopathic hypertrophic subaortic stenosis&#44; now known as HCM&#44; and underwent two septal myectomies in the early 1980s&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">An initial resting TTE showed evidence of SAM but a resting gradient of only 8<span class="elsevierStyleHsp" style=""></span>mmHg that increased to 22<span class="elsevierStyleHsp" style=""></span>mmHg during Valsalva maneuver &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Given the patient&#39;s family history of HCM and his worsening symptoms&#44; he was referred to a cardiologist for more targeted and dynamic investigations&#46; A cardiac MRI demonstrated hypertrophic anterolateral papillary muscle with abnormal insertion&#44; potential evidence of SAM&#44; but no clear gradient through the LVOT&#46; A cine CT demonstrated a septum of 13<span class="elsevierStyleHsp" style=""></span>mm with clear evidence of SAM &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Dynamic testing was done using treadmill exercise echocardiography&#44; which identified a maximal LVOT gradient during peak exercise was of 313<span class="elsevierStyleHsp" style=""></span>mmHg with evidence of mitral regurgitation &#40;MR&#41;&#46; The results of these tests led to the diagnosis of obstructive HCM with severe LVOT gradients during dynamic testing&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">During his diagnostic workup&#44; which took place over the course of several months&#44; the patients was increasingly symptomatic and reported NYHA class III symptoms despite maximal doses of disopyramide and bisoprolol&#46; After several discussions between the patient and his cardiologist&#44; he was referred for surgery due to failure of medical therapy&#46;</p></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Surgical management of HCM</span><p id="par0055" class="elsevierStylePara elsevierViewall">In 1959&#44; a group of British clinicians&#44; including Dr&#46; Teare and the surgeon Dr&#46; W&#46;P&#46; Cleland&#44; published a case report of a surgical treatment of obstructive cardiomyopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a> Nevertheless&#44; the name that is most frequently associated with the surgical management of HCM is Dr&#46; Andrew Morrow&#44; for whom the Morrow procedure is named and who was diagnosed with HCM himself&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> The Morrow procedure was the standard surgical approach to treating HCM for many years&#44; and involved a relatively limited resection of muscle from the basal septum&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Today&#44; surgeons perform an extended septal myectomy&#44; resecting significantly more tissue to better alleviate LVOT obstruction&#44; and many concomitantly address the anomalous chordae tendinae&#44; misaligned papillary muscles and other MV abnormalities&#46; Articles by Affronti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> and Gharibeh et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a> provide significant detail and context about the various approaches and techniques used to address the diversity of MV abnormalities seen in patients with HCM for the interested reader&#46; As well&#44; Kotkar and colleagues provides excellent illustrations of the diverse phenotypes they have observed in their HCM surgical program&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">It must be noted that although MV abnormalities are well described as a component of the HCM phenotype&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a> there is some controversy about the necessity of concomitant procedures of the MV and subvalvular apparatus during septal reduction surgery&#46; The Mayo clinic has described their extensive experience with the surgical management of HCM&#44; including descriptions of diverse MV anomalies&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> but their approach is generally to use septal myectomy alone to treat LVOT obstruction<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a> and suggest that this approach is sufficient for almost all patients&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> The surgical program at Toronto General Hospital&#44; one of the primary referral centers in Canada&#44; has published the results of their experience using isolated septal myectomy to treat HCM with good results&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">This approach contrasts with other centers that more routinely address MV anomalies during SRT&#46; A recent series by clinicians from Milan report that approximately half of HCM patients undergoing SRT required mitral valve intervention&#46; They reported that addressing the MV apparatus may be more important when patients do not have a particularly thick septum&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> The Cleveland Clinic similarly reports MV interventions in approximately a third of their SRT procedures for HCM&#44; and also noted the importance of addressing the MV in patients with thin septae&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> A report from Oregon is perhaps even more pronounced in its support of addressing MV anomalies&#59; Song and colleagues describe routine papillary muscle realignment in a cohort of patients undergoing SRT&#44; with very good results&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">At present there is no definitive consensus about whether addressing the MV apparatus is essential for alleviating LVOT obstruction&#46; The guidelines clearly reflect this controversy&#44; advising &#8220;transaortic extended septal myectomy&#8221; for patients with obstructive HCM who experience debilitating symptoms&#44; but note that &#8220;some centers achieve these results with isolated extended septal myectomy&#44; &#91;while&#93; other centers have found value in including revision of the anterior mitral leaflet or apparatus&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a></p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Case presentation</span><p id="par0080" class="elsevierStylePara elsevierViewall">The patient underwent a transesophageal echocardiogram &#40;TEE&#41; after the induction of anesthesia to evaluate the LVOT gradient and mechanism of obstruction&#46; Under resting conditions&#44; the TEE demonstrated a 13<span class="elsevierStyleHsp" style=""></span>mm septum&#44; hypertrophic anterior lateral papillary muscle group&#44; SAM without associated mitral insufficiency&#44; and a peak gradient of 30<span class="elsevierStyleHsp" style=""></span>mmHg&#46; A gradient was provoked with isoproterenol drip and nitroglycerine&#59; in these conditions&#44; the patient&#39;s LVOT gradient increased to 283<span class="elsevierStyleHsp" style=""></span>mmHg with torrential MR &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The patient underwent an extended septal myectomy&#44; with the resection of a segment approximately 30<span class="elsevierStyleHsp" style=""></span>mm by 35<span class="elsevierStyleHsp" style=""></span>mm by 7<span class="elsevierStyleHsp" style=""></span>mm at the level of the septum &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; Seven abnormal secondary chordae were resected &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>A&#8211;C&#41; followed by a realignment of the anterior lateral papillary muscle group towards the posterior medial papillary muscle group using a 4&#8211;0 Gore-Tex pledgeted suture &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>D&#41;&#46; Abnormal muscular connections between the septum and the base of the anterolateral papillary muscle group were resected allowing full mobility of the anterolateral papillary muscle group that was abnormally inserted&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The post-procedural TEE demonstrated normal coaptation between the anterior and posterior leaflets of the mitral valve&#44; with a coaptation point significantly displaced towards the posterior annulus &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46; There was no evidence of SAM&#44; and trace mitral insufficiency&#46; Under maximal provocation the peak gradient through the LVOT was 18<span class="elsevierStyleHsp" style=""></span>mmHg with a mean of 9<span class="elsevierStyleHsp" style=""></span>mmHg&#46; The patient had an uneventful postoperative course in hospital&#44; and was discharged home on post-operative day 4&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Our understanding of HCM has evolved over the past several decades&#44; and the contributions of the MV and subvalvular apparatus to the generation of LVOT obstruction is now well understood&#46; Myriad and diverse MV anomalies are accepted as part of the HCM phenotype&#44; and these must be considered when diagnosing and managing this complex disease&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">While there is some controversy about the necessity of addressing the MV during SRT&#44; many surgeons see it as an essential tool to eliminate SAM and alleviate obstruction&#46; The results of some experienced surgeons in high volume centers suggest that good alleviation of LVOT obstruction can be achieved through an isolated septal myectomy&#46; However&#44; the literature increasingly reflects a wider adoption of a variety of techniques to address the MV and apparatus with very good short- and mid-term results&#46; Many reports in the literature consistently suggest that addressing MV anomalies has led to the reliable elimination of SAM and reduction of LVOT obstructions under both resting and dynamic conditions&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">There is another potential consequence of a pointed focus on septal thickness and isolated myectomy to treat obstructive HCM&#44; and that is the potential exclusion of patients without significant septal hypertrophy from consideration for SRT&#46; Our case presentation was carefully chosen&#44; highlighting the profound dynamic obstruction and disabling symptoms that can be observed in an HCM patient with a relatively thin septum&#46; This young patient had been monitored for HCM due to his family history&#44; but the absence of a grossly hypertrophic septum resulted in his symptoms of exertional dyspnea being mis-diagnosed as exercise-induced asthma for many years&#46; After careful investigation by a cardiologist with expertise in cardiac MR and an interest in HCM&#44; his profound dynamic obstruction was diagnosed&#46; Interestingly&#44; this patient was discouraged from pursuing SRT at a large center that limits its practice to isolated septal myectomy&#44; as they did not feel confident that surgical intervention would improve this patient&#39;s symptoms or quality of life&#46; This patient experienced profound improvement in his symptoms following an extended septal myectomy with resection of anomalous chordae and realignment of his anterior lateral papillary muscles&#46; He has resumed regular activities&#44; including travel&#44; a busy work life and exercise&#46; It is important for clinicians to carefully consider the diverse mechanisms through which LVOT obstruction can be generated in patients with HCM&#44; and surgeons should be strongly encouraged to tailor their operation to the individual phenotype of each patient they bring to the OR&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">One other potential consideration when evaluating whether or not to integrate concomitant MV and apparatus procedures as part of the standard SRT is to consider if they might lend themselves to simplified or safer procedure with an easier learning curve&#46; The scarcity of septal myectomy surgeons has been acknowledged for many years&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a> The current supply in most countries is insufficient&#44; and many skilled myectomy surgeons are well into the latter years of their career&#46; Training the next generation of surgeons to perform SRT on patients with HCM is essential&#44; but the challenges and risks of the procedure make that training difficult&#46; In some ways&#44; surgical treatment of HCM today is similar to mitral valve repair twenty years ago&#44; with a variety of centers extolling the virtues of a diversity of techniques to treat a condition that is relatively common and afflicting a comparatively young patient population&#46; Modern MV repair is a safe and widely-available procedure&#44; and while there is still some variability in technique&#44; the preference has shifted away from leaflet resection and towards the use of Gore-Tex neochordae&#46; We would suggest that one reason for this is the ability to adjust or reverse the repair if needed&#59; once tissue is resected&#44; there is no way back&#46; Some techniques that address MV anomalies&#44; including realignment of papillary muscles using a pledgeted Gore-Tex suture&#44; also offer reversibility in case an adjustment is required&#46; One experienced myectomy surgeon reported that incorporating papillary muscle realignment into his SRT procedures reduced the need for more complicated MV techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> It is worth exploring whether some of these techniques might prove beneficial to surgeons during their learning curve&#44; to better ensure the elimination of SAM and LVOT obstruction in cases where a dramatic resection of septal tissue is either not possible or poses an unacceptable risk of creating an iatrogenic ventral septal defect &#40;VSD&#41;&#46; Given the urgent need to train more surgeons in these techniques&#44; no avenue should go unexplored&#46; If realigning papillary muscles or resecting anomalous chordae help a larger number of surgeons to safely and adequately address LVOT obstruction in patients with HCM&#44; certainly these techniques should be considered for wider adoption&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">When I &#40;JBG&#41; was first operating on patients with HCM&#44; I identified a need to protocolize the operation in order to ensure success&#46; I did not have the benefit of a fellowship in SRT&#44; I had the benefit of strong support from the HCM cardiologist at my institution&#44; who provided comprehensive support and extremely thorough diagnostic imaging&#46; The majority of my patients presented without severely hypertrophic septae&#44; and most had clear MV anomalies that were contributing to LVOT obstruction&#46; I devised a protocol for myself to approach each operation&#46; I began by resecting septal tissue to address that component of LVOT obstruction&#44; and to increase visibility into the ventricle&#46; Then I assess and resect any anomalous chordae&#46; Lastly&#44; I perform a realignment of the anterolateral papillary muscles&#46; This approach is tailored to each patient&#44; but I have found it to deliver consistent results for my patients&#44; and would suggest that approaching this very complex surgery in a clear&#44; linear manner helped to reduce my learning curve and allowed me to provide even my earliest patients with excellent results&#46; Let me note&#44; however&#44; that SRT is not an operation to be undertaken lightly&#46; I suspect that one of the reasons that there is a paucity of surgeons performing SRT is the potential for a single mistake to create catastrophic problems in a patient population that is often relatively young&#59; nobody wants to be responsible for a massive VSD or complete heart block in a 35 year old patient&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Finally&#44; we would respectfully advocate that those surgeons with the benefit of experience and a long history of successful cases should take steps to report their results more uniformly&#46; The reporting of MV anomalies&#44; SAM and MR is inconsistent and oftentimes missing from surgical case series in the literature&#44; which makes it difficult or impossible to compare patient populations and outcomes between centers with different surgical approaches&#46; If we are to move SRT from select high-volume centers to become a more widely-available technique&#44; we must share data&#44; compare outcomes&#44; and work collaboratively to identify which techniques can be broadly adopted and easily taught to the next generation of myectomy surgeons&#46; Too many patients find themselves desperately in need of SRT&#44; but with few or no experienced surgeons in their city or even their country to perform this life-changing operation&#46; HCM centers of all types should make a concerted effort to more clearly&#44; consistently and transparently report their experiences&#44; to the benefit of all&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Patients with HCM present with a diverse array of MV anomalies&#44; many of which contribute to LVOT obstruction&#46; While support for concomitant MV procedures during surgical myectomy is not universal&#44; there is strong support in the literature for excellent&#44; durable results when these procedures are undertaken&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Ethical disclosures</span><p id="par0130" class="elsevierStylePara elsevierViewall">The description of the case example in the article has been written in a way to not identify the patient&#44; and the patient provided written permission for his case example to be used&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors acknowledge the generous support of the <span class="elsevierStyleGrantSponsor" id="gs1">Cannstatter Foundation&#44; Inc</span>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare they have no conflict of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:13 [
        0 => array:3 [
          "identificador" => "xres1930438"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1663994"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres1930437"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec1663995"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Presence of MV abnormalities in HCM"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Case presentation"
            ]
          ]
        ]
        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Surgical management of HCM"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Case presentation"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Ethical disclosures"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Funding"
        ]
        10 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Conflict of interest"
        ]
        11 => array:2 [
          "identificador" => "xack675913"
          "titulo" => "Acknowledgements"
        ]
        12 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2022-01-30"
    "fechaAceptado" => "2022-02-04"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1663994"
          "palabras" => array:2 [
            0 => "Hypertrophic cardiomyopathy"
            1 => "Mitral valve"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1663995"
          "palabras" => array:2 [
            0 => "Miocardiopat&#237;a hipertr&#243;fica"
            1 => "Valvula mitral"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hypertrophic cardiomyopathy is increasingly understood to be a disease that presents not only with septal hypertrophy but also with diverse anomalies of the mitral valve and subvalvular apparatus&#46; In this review&#44; we describe the involvement of the mitral valve in the generation of left ventricular outflow tract obstruction in patients with hypertrophic cardiomyopathy&#44; and discuss the surgical approaches to managing this complex condition&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La cardiomiopat&#237;a hipertr&#243;fica est&#225; cada vez m&#225;s entendida como una enfermedad que se presenta no solo con evidencia de hipertrofia septal&#44; sino tambi&#233;n con diversas anormalidades de la v&#225;lvula mitral y su aparato subvalvular&#46; En este art&#237;culo describimos la contribuci&#243;n de la v&#225;lvula mitral a la generaci&#243;n de la obstrucci&#243;n del tracto de salida del ventr&#237;culo izquierdo en pacientes con cardiomiopat&#237;a hipertr&#243;fica obstructiva&#44; adem&#225;s de discutir los diferentes abordajes quir&#250;rgicos disponibles para tratar esta compleja patolog&#237;a&#46;</p></span>"
      ]
    ]
    "multimedia" => array:8 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 591
            "Ancho" => 1874
            "Tamanyo" => 79820
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Illustration of normal mitral leaflet coaptation and orientation of papillary muscles axis towards center of mitral valve allowing normal flow through LVOT &#40;A&#41; in contrast to turbulent flow through LVOT caused by abnormal orientation of hypertrophic anterolateral papillary muscle&#44; the presence of a mildly hypertophic sigmoid septum&#44; and secondary ectopic chordae tethering and bending the anterior leaflet of the mitral valve causing a hockey stick deformity&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1376
            "Ancho" => 1874
            "Tamanyo" => 199320
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A normal papillary muscle anatomy and coaptation between anterior and posterior leaflet of mitral valve with wide aorto ventricular angle &#40;left&#41; contrasts markedly with an abnormal anteriolateral papillary muscle group with it axis oriented towards the aortic valve instead of mitral valve &#40;right&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1278
            "Ancho" => 1674
            "Tamanyo" => 157236
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Resting Doppler echocardiogram with no evidence of MR or severe LOVOT obstruction&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Fig&#46; 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1200
            "Ancho" => 1207
            "Tamanyo" => 98337
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cine CT demonstrating systolic anterior motion of the mitral valve in the setting of a thin septum&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Fig&#46; 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 484
            "Ancho" => 1874
            "Tamanyo" => 111749
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Intraoperative transesophageal echocardiogram showing the presence of systolic anterior motion of the mitral valve &#40;A&#41;&#44; Doppler waveform with SAM but no mitral regurgitation &#40;B&#41;&#44; and a severe LVOT gradient with mitral regurgitation after the administration of isoproterenol&#44; dobutamine and nitroglycerine &#40;C&#41;&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Fig&#46; 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 1205
            "Ancho" => 905
            "Tamanyo" => 266693
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Surgical specimen consisting of resected septal tissue and anomalous chordae&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "fig0035"
        "etiqueta" => "Fig&#46; 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
            "Alto" => 1057
            "Ancho" => 1874
            "Tamanyo" => 243664
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Intraoperative images illustrating thickened ectopic chordae inserting into the base of the anterior leaflet of the mitral valve close to anterior trigon &#40;A&#41;&#44; ectopic secondary chordae inserting towards the posterior trigone anterior leaflet of the mitral valve B&#44; evidence of tethering effect of secondary chordae encircled by Prolene thread seen side-to-side with normal A2 segment of the anterior leaflet of the mitral valve being lifted by a nerve hook &#40;C&#41;&#44; and papillary muscle realignment using a 4&#8211;0 Gore-Tex suture tied over pledgets&#46;</p>"
        ]
      ]
      7 => array:7 [
        "identificador" => "fig0040"
        "etiqueta" => "Fig&#46; 8"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr8.jpeg"
            "Alto" => 582
            "Ancho" => 1874
            "Tamanyo" => 144243
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Post-procedural transesophageal echocardiogram demonstrating coaptation of the anterior and posterior leaflets of the mitral valve displaced towards the posterior annulus &#40;A&#41;&#59; trace mitral regurgitation during provocation with isoproterenol&#44; dobutamine and nitroglycerine &#40;B&#41;&#59; and peak and mean gradients under maximal provocation &#40;C&#41;&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:24 [
            0 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Asymmetrical hypertrophy of the heart in young adults"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "D&#46; Teare"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/hrt.20.1.1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br Heart J"
                        "fecha" => "1958"
                        "volumen" => "20"
                        "paginaInicial" => "1"
                        "paginaFinal" => "8"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13499764"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Obstructive cardiomyopathy simulating aortic stenosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;F&#46; Goodwin"
                            1 => "A&#46; Hollman"
                            2 => "W&#46;P&#46; Cleland"
                            3 => "D&#46; Teare"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/hrt.22.3.403"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br Heart J"
                        "fecha" => "1960"
                        "volumen" => "22"
                        "paginaInicial" => "403"
                        "paginaFinal" => "414"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13851098"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "From Teare to the present day&#58; a fifty year odyssey in hypertrophic cardiomyopathy&#44; a paradigm for the logic of the discovery process"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "W&#46;J&#46; McKenna"
                            1 => "S&#46; Sen-Chowdhry"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/s1885-5857(09)60050-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Cardiol"
                        "fecha" => "2008"
                        "volumen" => "61"
                        "paginaInicial" => "1239"
                        "paginaFinal" => "1244"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19080961"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Contemporary treatment of hypertrophic cardiomyopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "A&#46;J&#46; Marian"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Tex Heart Inst J"
                        "fecha" => "2009"
                        "volumen" => "36"
                        "paginaInicial" => "194"
                        "paginaFinal" => "204"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19568388"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The mitral valve in obstructive hypertrophic cardiomyopathy&#58; a test in context"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46;V&#46; Sherrid"
                            1 => "S&#46; Balaram"
                            2 => "B&#46; Kim"
                            3 => "L&#46; Axel"
                            4 => "D&#46;G&#46; Swistel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2016.01.071"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2016"
                        "volumen" => "67"
                        "paginaInicial" => "1846"
                        "paginaFinal" => "1858"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27081025"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The mitral valve in hypertrophic cardiomyopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Woo"
                            1 => "S&#46; Jedrzkiewicz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.111.035568"
                      "Revista" => array:7 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2011"
                        "volumen" => "124"
                        "paginaInicial" => "9"
                        "paginaFinal" => "12"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21730319"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S1201971215001174"
                          "estado" => "S300"
                          "issn" => "12019712"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2020 AHA&#47;ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;R&#46; Ommen"
                            1 => "S&#46; Mital"
                            2 => "M&#46;A&#46; Burke"
                            3 => "S&#46;M&#46; Day"
                            4 => "A&#46; Deswal"
                            5 => "P&#46; Elliott"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIR.0000000000000937"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2020"
                        "volumen" => "142"
                        "paginaInicial" => "e558"
                        "paginaFinal" => "e631"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33215931"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anomalous insertion of papillary muscle directly into anterior mitral leaflet in hypertrophic cardiomyopathy&#46; Significance in producing left ventricular outflow obstruction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "H&#46;G&#46; Klues"
                            1 => "W&#46;C&#46; Roberts"
                            2 => "B&#46;J&#46; Maron"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/01.cir.84.3.1188"
                      "Revista" => array:7 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "1991"
                        "volumen" => "84"
                        "paginaInicial" => "1188"
                        "paginaFinal" => "1197"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1884449"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0303846714001590"
                          "estado" => "S300"
                          "issn" => "03038467"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diversity of structural mitral valve alterations in hypertrophic cardiomyopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "H&#46;G&#46; Klues"
                            1 => "B&#46;J&#46; Maron"
                            2 => "A&#46;L&#46; Dollar"
                            3 => "W&#46;C&#46; Roberts"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/01.cir.85.5.1651"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "1992"
                        "volumen" => "85"
                        "paginaInicial" => "1651"
                        "paginaFinal" => "1660"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1572023"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Abnormal papillary muscle morphology is independently associated with increased left ventricular outflow tract obstruction in hypertrophic cardiomyopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;H&#46; Kwon"
                            1 => "R&#46;M&#46; Setser"
                            2 => "M&#46; Thamilarasan"
                            3 => "Z&#46;V&#46; Popovic"
                            4 => "N&#46;G&#46; Smedira"
                            5 => "P&#46; Schoenhagen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/hrt.2007.118018"
                      "Revista" => array:6 [
                        "tituloSerie" => "Heart"
                        "fecha" => "2008"
                        "volumen" => "94"
                        "paginaInicial" => "1295"
                        "paginaFinal" => "1301"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17690158"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mitral valve abnormalities identified by cardiovascular magnetic resonance represent a primary phenotypic expression of hypertrophic cardiomyopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;S&#46; Maron"
                            1 => "I&#46; Olivotto"
                            2 => "C&#46; Harrigan"
                            3 => "E&#46; Appelbaum"
                            4 => "C&#46;M&#46; Gibson"
                            5 => "J&#46;R&#46; Lesser"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.110.985812"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2011"
                        "volumen" => "124"
                        "paginaInicial" => "40"
                        "paginaFinal" => "47"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21670234"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Isolated septal myectomy for hypertrophic obstructive cardiomyopathy&#58; an update on the Toronto General Hospital experience"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R&#46;D&#46; Vanderlaan"
                            1 => "A&#46; Woo"
                            2 => "A&#46; Ralph-Edwards"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Ann Cardiothorac Surg"
                        "fecha" => "2017"
                        "volumen" => "6"
                        "paginaInicial" => "364"
                        "paginaFinal" => "368"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The surgical management of hypertrophic obstructive cardiomyopathy with the concomitant mitral valve abnormalities"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "B&#46; Cui"
                            1 => "S&#46; Wang"
                            2 => "J&#46; Xu"
                            3 => "W&#46; Wang"
                            4 => "Y&#46; Song"
                            5 => "H&#46; Sun"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/icvts/ivv257"
                      "Revista" => array:6 [
                        "tituloSerie" => "Interact Cardiovasc Thorac Surg"
                        "fecha" => "2015"
                        "volumen" => "21"
                        "paginaInicial" => "722"
                        "paginaFinal" => "726"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26374266"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mitral valve abnormalities in hypertrophic cardiomyopathy&#58; echocardiographic features and surgical outcomes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46;K&#46; Kaple"
                            1 => "R&#46;T&#46; Murphy"
                            2 => "L&#46;M&#46; DiPaola"
                            3 => "P&#46;L&#46; Houghtaling"
                            4 => "H&#46;M&#46; Lever"
                            5 => "B&#46;W&#46; Lytle"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.athoracsur.2008.01.061"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Thorac Surg"
                        "fecha" => "2008"
                        "volumen" => "85"
                        "paginaInicial" => "1527"
                        "paginaFinal" => "1535"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18442532"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hypertrophic obstructive cardiomyopathy&#58; the Mayo Clinic experience"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "K&#46;D&#46; Kotkar"
                            1 => "S&#46;M&#46; Said"
                            2 => "J&#46;A&#46; Dearani"
                            3 => "H&#46;V&#46; Schaff"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.21037/acs.2017.07.03"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Cardiothorac Surg"
                        "fecha" => "2017"
                        "volumen" => "6"
                        "paginaInicial" => "329"
                        "paginaFinal" => "336"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28944173"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The father of septal myectomy for obstructive HCM&#44; who also had HCM&#58; the unbelievable story"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "B&#46;J&#46; Maron"
                            1 => "W&#46;C&#46; Roberts"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2016.05.002"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2016"
                        "volumen" => "67"
                        "paginaInicial" => "2900"
                        "paginaFinal" => "2903"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27311529"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Surgery for hypertrophic obstructive cardiomyopathy&#58; comprehensive LVOT management beyond septal myectomy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Affronti"
                            1 => "R&#46; Pruna-Guillen"
                            2 => "E&#46; Sandoval"
                            3 => "D&#46; Pereda"
                            4 => "J&#46; Alcocer"
                            5 => "M&#46; Castell&#224;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "J Clin Med"
                        "fecha" => "2021"
                        "volumen" => "10"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comprehensive left ventricular outflow tract management beyond septal reduction to relieve obstruction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46; Gharibeh"
                            1 => "N&#46;G&#46; Smedira"
                            2 => "J&#46;B&#46; Grau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Asian Cardiovasc Thorac Ann"
                        "fecha" => "2021"
                        "itemHostRev" => array:3 [
                          "pii" => "S1529943016311287"
                          "estado" => "S300"
                          "issn" => "15299430"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of the mitral valve in patients with obstructive hypertrophic cardiomyopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;H&#46; Hong"
                            1 => "A&#46; Nguyen"
                            2 => "H&#46;V&#46; Schaff"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s12055-019-00817-y"
                      "Revista" => array:7 [
                        "tituloSerie" => "Indian J Thorac Cardiovasc Surg"
                        "fecha" => "2020"
                        "volumen" => "36"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "34"
                        "paginaFinal" => "43"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33061183"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Is anterior mitral valve leaflet length important in outcome of septal myectomy for obstructive hypertrophic cardiomyopathy&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Lentz Carvalho"
                            1 => "H&#46;V&#46; Schaff"
                            2 => "R&#46;A&#46; Nishimura"
                            3 => "S&#46;R&#46; Ommen"
                            4 => "J&#46;B&#46; Geske"
                            5 => "B&#46;D&#46; Lahr"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:2 [
                        "tituloSerie" => "J Thorac Cardiovasc Surg"
                        "fecha" => "2021"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hypertrophic cardiomyopathy with moderate septal thickness and mitral regurgitation&#58; long-term surgical results"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46; Lapenna"
                            1 => "T&#46; Nisi"
                            2 => "D&#46; Carino"
                            3 => "M&#46; Bargagna"
                            4 => "S&#46; Ruggeri"
                            5 => "E&#46; Zancanaro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/ejcts/ezab097"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Cardiothorac Surg"
                        "fecha" => "2021"
                        "volumen" => "60"
                        "paginaInicial" => "244"
                        "paginaFinal" => "251"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33624799"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Surgical management of left ventricular outflow tract obstruction in a specialized hypertrophic obstructive cardiomyopathy center"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "K&#46; Hodges"
                            1 => "C&#46;G&#46; Rivas"
                            2 => "J&#46; Aguilera"
                            3 => "R&#46; Borden"
                            4 => "A&#46; Alashi"
                            5 => "E&#46;H&#46; Blackstone"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jtcvs.2018.11.148"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Thorac Cardiovasc Surg"
                        "fecha" => "2019"
                        "volumen" => "157"
                        "paginaInicial" => "2289"
                        "paginaFinal" => "2299"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30782406"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Routine papillary muscle realignment and septal myectomy for obstructive hypertrophic cardiomyopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;K&#46; Song"
                            1 => "J&#46; Turner"
                            2 => "R&#46; Macfie"
                            3 => "S&#46; Kumar"
                            4 => "M&#46;J&#46; Mannello"
                            5 => "D&#46; Smith"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.athoracsur.2018.04.026"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Thorac Surg"
                        "fecha" => "2018"
                        "volumen" => "106"
                        "paginaInicial" => "670"
                        "paginaFinal" => "675"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29753818"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Why we need more septal myectomy surgeons&#58; an emerging recognition"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "B&#46;J&#46; Maron"
                            1 => "J&#46;A&#46; Dearani"
                            2 => "M&#46;S&#46; Maron"
                            3 => "S&#46;R&#46; Ommen"
                            4 => "H&#46; Rastegar"
                            5 => "R&#46;A&#46; Nishimura"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jtcvs.2016.12.038"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Thorac Cardiovasc Surg"
                        "fecha" => "2017"
                        "volumen" => "154"
                        "paginaInicial" => "1681"
                        "paginaFinal" => "1685"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28268009"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
    "agradecimientos" => array:1 [
      0 => array:4 [
        "identificador" => "xack675913"
        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0145" class="elsevierStylePara elsevierViewall">The authors wish to acknowledge the generous support of the Canstatter Foundation&#44; Inc&#46; We also wish to express our thanks to Paloma Segura Amoros for her illustrations&#44; and to the patient described in this article&#44; who provided permission for details of his case to be used&#46;</p>"
        "vista" => "all"
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/11340096/00000029000000S1/v2_202307141006/S1134009622000286/v2_202307141006/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "94680"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Revisiones"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/11340096/00000029000000S1/v2_202307141006/S1134009622000286/v2_202307141006/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1134009622000286?idApp=UINPBA00004N"
]

Article information

ISSN: 11340096
Original language: English

DOI:10.1016/j.circv.2022.02.006

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	5	2	7
2024 October	57	20	77
2024 September	59	17	76
2024 August	62	22	84
2024 July	40	24	64
2024 June	42	16	58
2024 May	42	12	54
2024 April	34	14	48
2024 March	41	6	47
2024 February	37	12	49
2024 January	53	9	62
2023 December	50	14	64
2023 November	68	6	74
2023 October	70	12	82
2023 September	44	3	47
2023 August	55	14	69
2023 July	41	11	52
2023 June	50	5	55
2023 May	67	6	73
2023 April	48	2	50
2023 March	9	6	15
2023 February	12	12	24
2023 January	10	7	17
2022 December	13	4	17
2022 November	18	13	31
2022 October	15	15	30
2022 September	19	10	29
2022 August	17	5	22
2022 July	23	6	29
2022 June	19	13	32
2022 May	8	11	19

Show all

Indexed in:

Follow us:

Statistics

Indexed in:

Follow us:

Statistics

Subscribe to our newsletter