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Ann Thorac Surg 2000;69:1735-1736
© 2000 The Society of Thoracic Surgeons
DR CONSTANTINE MAVROUDIS (Chicago, IL): That was a terrific presentation of almost unprecedented results—no heart block, no resultant ventricular septal defect, and no mortality. I think that these results are even better than the recent Mayo Clinic series. I just have a question concerning technique. The first part is that we found that if we transect the aorta we have a better view through the aortic valve for a myectomy, and in addition we have used skin hooks to retract the muscle and hold it in tension while we do the myectomy. Did you use these two techniques for your spectacular results and what do you think of them?
DR MERRILL: Thank you. I will speak only for myself and not my coauthors. I would just say that we have been very fortunate to have good results.
Doctor Bender, one of my colleagues, and an important contributor in this series, makes the point that it is incredibly important to set up the exposure so that the aortic valve and the subvalvular area are visualized very well. He has taught us to use a nasal speculum or aortic root retractor to distract the aortic valve leaflets, thereby facilitating good exposure of the area underneath the aortic valve.
I think this is an operation that is not particularly easy to perform. It seems easy in concept, but the actual resection of muscle is sometimes difficult. We have thought it is very important to take adequate time to get the exposure all set up, to make sure we can see what we want to see, and to try to do an aggressive myectomy.
DR WILLIAM A. BAUMGARTNER (Baltimore, MD): That was a great presentation and, like Dr. Mavroudis said, wonderful results. You do not see very many of these cases. We only do three or four operations a year like Dr Morrow described, and we too have found that the transesophageal echo is a wonderful adjunct to this technique. Occasionally we have had to take more muscle out; it was clearly not enough, and so I agree with you completely.
One small technical point is that, unlike Dr Morrow’s pictures, where he uses a lighted ribbon retractor, we actually stuff a four-by-four gauze in the outflow tract, then put the retractor in. This will completely cover most of the subvalvular apparatus. The chordae can slip up on the ribbon retractor in the process.
I also wanted to say that the symptomatic results after this operation are dramatic. You can achieve the same results with replacement of the mitral valve, as Dr Cooley I think recommends, but that leaves the patient with all the complications associated with a prosthetic mitral valve. So this operation gives you tremendous results.
I had one question; would you comment on the more recent information describing the alcohol injection of the first septal perforator as a noninvasive way to treat this disease?
DR MERRILL: Than you, Dr Baumgartner. As you know, alcohol injection has been proposed as a treatment option. We have no experience with that in our own institution. I am sure that it has its good and bad points and its own set of complications, but I really could not comment further.
DR NABIL A. MUNFAKH (New Orleans, LA): I enjoyed your presentation. My question is, at the end of the operation what do you consider to be an acceptable gradient, and do you use the transesophageal echocardiographic gradient alone, do you use the actual ventricular gradient measured with a spinal needle, or do you stress the patient with intropic agents to determine the effects of the operation?
DR MERRILL: That is an excellent question, and I am sorry but I do not have a defined or precise answer. We have used transesophageal echocardiography in recent years. We have not developed a specific protocol for various maneuvers in an attempt to either reduce or increase the gradient. We have accepted a resting gradient of somewhere between 0 and 25 mm Hg if we thought there was a readily visible trough that suggested that we had done an adequate resection. You could make all sorts of arguments that we need to develop a more precise protocol, and that is a good suggestion for future investigation.
DR THORALF M. SUNDT III (St. Louis MO): Those are spectacular results, and my question really echos the two previous ones in the use of transesophageal echocardiography. I have to admit to occasionally growing faint of heart when resecting some of that muscle and am fearful that I have done too little rather than too much on occasion. Have you returned to bypass to resect more muscle? I am interested to hear that Dr Baumgartner has done so.
DR MERRILL: We have been fortunate in that our resections have been, at least in our judgment, adequate on the first attempt. I think that we have used what I consider a fairly aggressive approach in terms of taking out a big piece of muscle the first time around. In addition to the myectomy using the three big incisions, as advocated by Dr Morrow, we have also used fairly liberal scissor dissection to add to the resection. Fortunately, it has worked out well.
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