Transmitral Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy Brody Wehman, MD, Mehrdad Ghoreishi, MD, Nathaniel Foster, BS, Libin Wang, MD,

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Transmitral Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy Brody Wehman, MD, Mehrdad Ghoreishi, MD, Nathaniel Foster, BS, Libin Wang, MD, Michael N. D'Ambra, MD, Nathan Maassel, BS, Sam Maghami, MD, Rachael Quinn, PhD, Murtaza Dawood, MD, Stacy Fisher, MD, James S. Gammie, MD The Annals of Thoracic Surgery Volume 105, Issue 4, Pages 1102-1108 (April 2018) DOI: 10.1016/j.athoracsur.2017.10.045 Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Operative technique for transmitral septal myectomy. (A) Sharp dissection of anterior mitral leaflet from its base provides wide exposure of the ventricular septum. (B, C) Septal resection extends in a counter-clockwise fashion from the 12-o’clock to the 8-o’clock position. (D) After myectomy, the anterior leaflet is reattached, and necessary mitral valve repair is performed, including ring annuloplasty. (E) In some cases, a curtain stitch is useful to reposition the lateral aspect of the anterior leaflet out of the left ventricular outflow tract. A horizontal mattress suture (with or without a pledget) is placed to join the coapting surfaces (not the free edges) of the anterior and posterior leaflets at the anterolateral commissure and brought through the annuloplasty ring. The Annals of Thoracic Surgery 2018 105, 1102-1108DOI: (10.1016/j.athoracsur.2017.10.045) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Preoperative grade of mitral regurgitation by transthoracic echocardiogram. The Annals of Thoracic Surgery 2018 105, 1102-1108DOI: (10.1016/j.athoracsur.2017.10.045) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Preoperative (Pre) and postoperative (Post) reduction in (A) width of basal interventricular septum (18.2 ± 3.8 mm versus 12.1 ± 3.0 mm, p < 0.0001) and (B) left ventricular outflow tract (LVOT) gradient (92.8 ± 42.9 mm Hg versus 10.9 ± 5.1 mm Hg, p < 0.0001) after transmitral septal myectomy. The Annals of Thoracic Surgery 2018 105, 1102-1108DOI: (10.1016/j.athoracsur.2017.10.045) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions