Beyond Extended Myectomy for Hypertrophic Cardiomyopathy: The Resection- Plication-Release (RPR) Repair Sandhya K. Balaram, MD, PhD, Mark V. Sherrid,

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Beyond Extended Myectomy for Hypertrophic Cardiomyopathy: The Resection- Plication-Release (RPR) Repair Sandhya K. Balaram, MD, PhD, Mark V. Sherrid, MD, Joseph J. Derose, MD, Zak Hillel, MD, PhD, Glenda Winson, RN, Daniel G. Swistel, MD The Annals of Thoracic Surgery Volume 80, Issue 1, Pages 217-223 (July 2005) DOI: 10.1016/j.athoracsur.2005.01.064 Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Resection: A trefoil retractor is used to grasp the septal bulge to allow stabilization and a more complete resection of the septum. Resection of the ventricular septum has evolved to include extended resection deep into the ventricular cavity. It is important to plan the length of septal myectomy preoperatively with detailed measurement by transthoracic echocardiography and transesophageal echocardiography. Resection of the area just proximal to the aortic annulus is avoided; rather, resection is focused on the anterior septum beginning 1 cm below the aortic annulus. The midseptal bulge often extends as much as 4 cm toward the base of the papillary muscles based on preoperative echocardiograms. The goal of the resection should be not only to increase the size of the outflow tract but also to redirect flow anterior and medially, away from the mitral valve. Indeed, the three components of the RPR (resection-plication-release) operation are designed to separate the inflow and outflow portions of the left ventricle that pathologically overlap in obstructive hypertrophic cardiomyopathy. The Annals of Thoracic Surgery 2005 80, 217-223DOI: (10.1016/j.athoracsur.2005.01.064) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Plication: To decrease redundancy, horizontal plication of the anterior leaflet is performed using interrupted prolene sutures. Transaortic anterior mitral leaflet plication, as described here, has several advantages as a concomitant procedure. It specifically addresses underlying mechanisms of systolic anterior motion: redundancy of the mitral leaflet and chordal slack. Based on preoperative echocardiography, the presence of an enlarged, floppy anterior leaflet may be diagnosed and treated with this horizontal plication. The Annals of Thoracic Surgery 2005 80, 217-223DOI: (10.1016/j.athoracsur.2005.01.064) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Release: Careful examination of the papillary muscles is performed. The hypertrophic cardiomyopathy disease process can result in abnormal connections between the anterior papillary muscles and the anterior free wall. This abnormal connection displaces the mitral leaflets into the outflow tract. Sharp and blunt dissection of these connections releases the anterior papillary muscle (inset), allowing the valve to fall back into the left ventricular cavity explicitly out of the flow stream. The Annals of Thoracic Surgery 2005 80, 217-223DOI: (10.1016/j.athoracsur.2005.01.064) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Preoperative and postoperative transesophageal long-axis echocardiograms of a 46-year-old hypertrophic cardiomyopathy patient with severe left ventricle outflow tract obstruction and a preoperative gradient greater than 100 mm Hg. (Top) Preoperatively, significant left ventricular outflow tract obstruction is shown with an elongated floppy anterior mitral leaflet. (AV= aortic valve; LA= left atrium; LV= left ventricle; MV= mitral valve; PRE CPB= before cardiopulmonary bypass.) (Bottom) Postoperative view after extended myectomy, plication of the anterior leaflet, and release of papillary muscles. (POSTCPB= after cardiopulmonary bypass.) The Annals of Thoracic Surgery 2005 80, 217-223DOI: (10.1016/j.athoracsur.2005.01.064) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Preoperative and postoperative parasternal diastolic long-axis transthoracic echocardiograms in a 44-year-old man with symptomatic drug-refractory obstructive hypertrophic cardiomyopathy. (Left) The preoperative images show septal hypertrophy and a large mitral valve anterior leaflet. (Right) The postoperative image shows a very small myectomy resection (arrow) predominantly localized in the area just below the aortic valve. The large anterior mitral leaflet remains. The Annals of Thoracic Surgery 2005 80, 217-223DOI: (10.1016/j.athoracsur.2005.01.064) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions