Circulation, Vol 52, 88-102, Copyright © 1975 by American Heart Association
AG Morrow, BA Reitz, SE Epstein, WL Henry, DM Conkle, SB Itscoitz and DR Redwood
The results of operative treatment in 83 patients with idiopathic
hypertrophic subaortic stenosis (IHSS) are described. Most patients with
the disease are asymptomatic, or derive satisfactory symptomatic
improvement from nonoperative therapy: administration of propranolol,
exerice limitation, control of arrhythmia, etc. Operation is required,
however, in 10-15% of patients, those who remain severely symptomatic after
nonoperative treatment or who become refractory to it. Operation relieves
symptoms in IHSS by relieving obstruction to left ventricular outflow, and
for a patient to be considered an operative candidate severe obstruction
must be documented at left heart catheterization either under resting
conditions or after provocative interventions. All 83 patients were
severely incapacitated--58 in Class III and 24 in Class IV. Seventy had
obstruction at rest (average gradient 96 mm Hg), and 13 had only provocable
obstruction. At operation the hypertrophic interventricular septum was
exposed via an aortotomy, and a vertical bar of muscle was resected between
parallel myotomy incisions. There were six operative deaths (7%); no
patient has died since 1970. Seven patients have died late after operation,
five of them from causes unrelated to their heart disease or the operation.
All surviving patients describe symptomatic improvement. Fifty-two patients
with obstruction at rest preoperatively (average gradient 95 mm Hg) have
been studied postoperatively: no resting gradient was evident in 47, while
in the remaining five the gradient was less than 25 mm Hg. Recurrence of
obstruction has never been observed at late catheterization (21 pts) or
late echocardiographic examination (37 pts). Obstruction could not be
provoked postoperatively in ten of the 11 patients who had large gradients
only with the Valsalva maneuver or isoproterenol administration
preoperatively. Obstructed and provocable obstructed patients had similar
symptomatic improvement after operation. A variety of rhythm and conduction
abnormalities were observed both pre and postoperatively, and these are
described in detail. The results of operation in these 83 patients with
IHSS demonstrate that gratifying symptomatic and hemodynamic improvement
uniformly follows left ventriculomyotomy and myectomy. Relief of
obstruction and amelioration of symptoms have proved to be long-lasting
during postoperative observation periods extending to 14 years. Continued
application of the operative procedure in properly selected patients
appears to be indicated.
ARTICLES
Operative treatment in hypertrophic subaortic stenosis. Techniques, and the results of pre and postoperative assessments in 83 patients
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