Association Between Three-Dimensional Left Ventricular Outflow Tract Area and Gradients After Myectomy in Hypertrophic Obstructive Cardiomyopathy

Objective

Determine whether the intraoperative three-dimensional left ventricular outflow tract cross-sectional area may be inversely correlated with pressure gradients as a determinant of surgical success after septal myectomy in hypertrophic cardiomyopathy patients.

Design

Perioperative data were obtained by retrospective review.

Setting

Toronto General Hospital, University of Toronto, Toronto, Canada, a tertiary hospital.

Participants

The study comprised 67 patients with hypertrophic obstructive cardiomyopathy.

Interventions

Transthoracic and intraoperative transesophageal echocardiographic assessment of pressure gradients. Transesophageal measurement of the three-dimensional left ventricular outflow tract cross-sectional area.

Measurements and Main Results

The smallest left ventricular outflow tract area increased on average 1.883 cm² (98.3%) after septal myectomy. There was a significant correlation between the increase in the area and the transesophageal pressure gradients (r = –0.32; p = 0.01) after myectomy, but none with postoperative transthoracic gradients at rest (r = –0.10; p = 0.42). Postoperative transesophageal and transthoracic gradients were significantly correlated (r = 0.26; p = 0.04). The best risk factors to predict high residual gradients were preoperative transesophageal gradient >97 mmHg, postoperative transesophageal area <3.16 cm², and moderate or more residual transesophageal mitral regurgitation (specificity 89%, 81%, and 78%, respectively).

Conclusions

Three-dimensional left ventricular outflow tract area measurements with transesophageal echocardiography after myectomy correlated fairly well with postoperative transesophageal pressure gradients. Patients with residual transthoracic elevated gradients after surgery at follow-up had a smaller transesophageal area and higher transesophageal pressure gradients immediately after the procedure. However, transesophageal pressure gradients after myectomy correlated poorly with follow-up transthoracic gradients at rest.