This case demonstrates the feasibility and reproducibility of a totally endoscopic approach for septal myectomy, combining the effectiveness of conventional surgery with the advantages of a non-sternotomy technique.
Key Findings
Methods
A totally endoscopic transaortic septal myectomy was successfully performed in a symptomatic patient with severe left ventricular outflow tract obstruction and systolic anterior motion of the mitral valve.
The patient presented with marked asymmetric septal hypertrophy, hyperdynamic ventricular function, and significant outflow tract gradient preoperatively.
The procedure utilized a totally endoscopic approach with femoro-femoral cardiopulmonary bypass and transthoracic aortic cross-clamping.
Access was achieved via a non-sternotomy technique, and the myectomy was performed after pericardial opening and aortotomy.
Three-dimensional endoscopic visualization was used during the transaortic septal myectomy.
Results
Intraoperative transoesophageal echocardiography confirmed resolution of systolic anterior motion and marked reduction of left ventricular outflow tract obstruction.
Systolic anterior motion of the mitral valve was confirmed absent intraoperatively by transoesophageal echocardiography.
Marked reduction of outflow tract obstruction was demonstrated intraoperatively.
This finding confirmed the procedural effectiveness of the endoscopic approach in achieving the surgical goals comparable to conventional open surgery.
Results
Postoperative transthoracic echocardiography demonstrated preserved ventricular function, absence of systolic anterior motion, and a peak gradient of 18 mmHg.
Postoperative peak left ventricular outflow tract gradient was 18 mmHg.
Ventricular function was preserved following the procedure.
Systolic anterior motion of the mitral valve was absent on postoperative imaging.
These results indicate successful relief of outflow tract obstruction without compromise of ventricular function.
Discussion
The totally endoscopic approach for septal myectomy was highlighted as feasible and reproducible, combining the effectiveness of conventional surgery with the advantages of a non-sternotomy technique.
The case report emphasizes that the endoscopic technique can replicate the surgical outcomes of traditional open septal myectomy, which is considered the gold standard for symptomatic patients unresponsive to medical therapy.
The non-sternotomy approach offers potential advantages associated with minimally invasive cardiac surgery.
The authors describe the approach as both feasible and reproducible based on this case.
Surgical septal myectomy is noted as the gold standard for symptomatic hypertrophic obstructive cardiomyopathy patients not responding to medical therapy.
What This Means
Hypertrophic obstructive cardiomyopathy (HOCM) is a heart condition where the heart muscle becomes abnormally thick, blocking blood flow out of the heart. The standard surgical treatment requires opening the chest through the breastbone (sternotomy) to remove excess heart muscle. This case report describes a patient with HOCM who underwent a fully endoscopic version of this surgery — meaning the operation was performed through small keyhole incisions using a camera and specialized instruments, without cutting through the breastbone.
The surgical team used a bypass machine connected through blood vessels in the groin, clamped the aorta through the chest wall, and performed the muscle removal while viewing the operative field through a three-dimensional camera system. Both during and after the operation, ultrasound imaging of the heart confirmed that the obstruction was successfully relieved, the abnormal valve movement that contributes to the blockage was eliminated, and heart function remained normal. The post-operative pressure gradient across the outflow tract measured only 18 mmHg, indicating effective relief of obstruction.
This research suggests that totally endoscopic septal myectomy is technically feasible and can achieve results comparable to traditional open-heart surgery for HOCM, while potentially offering the benefits of minimally invasive surgery such as smaller incisions and possibly faster recovery. As a single case report, it serves as a proof-of-concept and provides a technical description that other surgeons could reference, though larger studies would be needed to more fully evaluate outcomes across many patients.