136 ª 2023 by The Society of Thoracic Surgeons 0003-4975/$36.

00
Published by Elsevier Inc. https://doi.org/10.1016/j.athoracsur.2022.08.018

Congenital & Pediatric: Research

Incidence of Reoperation After Surgical

Procedure for Left Ventricular Outflow Tract
Obstruction in Children and Young Adults
Benish Fatima, MD, Hartzell V. Schaff, MD, Elizabeth H. Stephens, MD, PhD,
Katherine S. King, MS, Frank Cetta, MD, and Joseph A. Dearani, MD

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota; Division of Clinical Trials and Biostatistics,
Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota; and Division of Pediatric Cardiology,
Mayo Clinic, Rochester, Minnesota

ABSTRACT

BACKGROUND The common causes of subaortic left ventricular outflow tract obstruction (LVOTO) are hypertrophic
cardiomyopathy (HCM) and membranous/tunnel subaortic stenosis (SAS). Reoperation after corrective surgery may be
due to recurrent disease, associated congenital defects, or complications of the initial procedure. This study compares
the late outcomes of young patients with HCM and SAS.

METHODS We studied clinical, echocardiographic, and operative data of patients £21 years of age at the time of
surgery for LVOTO between August 1963 and August 2018. We stratified patients into HCM (n [ 152) and congenital
SAS (n [ 63) groups and compared survival and cumulative incidence of reoperation.

RESULTS At initial repair, patients with HCM were older than patients with SAS (median [interquartile range] age, 15
[10-19] years vs 8 [5-13] years; P < .001), and patients with HCM were more symptomatic with dyspnea (P < .001), chest
pain (P [ .002), and presyncope/syncope (P [ .005). Thirty-day mortality was 1.3% vs 0% for HCM and SAS groups.
During a median follow-up of 13.1 years, survival was similar through the first 10 years; but during the second decade,
patients with HCM had poorer survival (survival at 20 years, 80% vs 91% for patients with SAS; P [ .007). Ten years after
repair, reoperation for recurrent LVOTO was performed in 5% of patients with HCM vs 31% in those with SAS (P < .001).

CONCLUSIONS In this surgical cohort, patients with HCM were more symptomatic preoperatively than those with SAS.
Late survival of patients with SAS was superior to that of patients with HCM despite a greater need for reoperation.
(Ann Thorac Surg 2023;115:136-43)
ª 2023 by The Society of Thoracic Surgeons

H ypertrophic cardiomyopathy (HCM)

congenital subaortic stenosis (SAS) are 2 com-
mon causes of left ventricular outflow tract
obstruction (LVOTO) in young patients. During repair
and
of these conditions in children, the limited surgical field
may increase the risk of injury to the aortic and mitral
valves as well as the risk of creating a ventricular septal
defect. Furthermore, correction of LVOTO in childhood
may have the late complication of recurrent obstruction
due to incomplete resection during initial surgical pro-
cedure or tissue regrowth.1
There are conflicting data on outcomes of operations
for HCM and SAS in young patients; both conditions
have risks of recurrence, but mechanisms appear to be
different.2 In HCM, common mechanisms for recurrence
include limited myectomy at the initial operation,
unrecognized or late-developing midventricular
obstruction, anomalies of papillary muscles, and ven-
tricular remodeling.3 In patients with SAS, risk factors
for recurrent obstruction include female sex, younger
age at the time of surgery, and failure to perform
The Supplemental Tables can be viewed in the online version of this
article [10.1016/j.athoracsur.2022.08.018] on http://www.
annalsthoracicsurgery.org.

Accepted for publication Aug 8, 2022.

Presented as an ePoster at the Fifty-seventh Annual Meeting of The Society of Thoracic Surgeons, Virtual Meeting, Jan 29-31, 2021.
Address correspondence to Dr Schaff, Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905; email: schaff@mayo.edu.

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Ann Thorac Surg
2023;115:136-43
septal myectomy in conjunction with membrane
resection.4,5 The purpose of this study was to compare
the reoperation rates and survival after correction of
LVOTO in patients
21 years of age with HCM and SAS.
PATIENTS AND METHODS
STUDY POPULATION. This investigation, approved by
the institutional review board (#18-002278) in February
2020, included patients who underwent the index
corrective operation for LVOTO between August 1963
and August 2018 at Mayo Clinic, Rochester, Minnesota.
Patients who did not authorize their records for
research were excluded. We analyzed available clinical,
echocardiographic, operative, and postoperative data
of patients who were
21 years of age. Patients who
underwent apical myectomy or had midcavitary/
nonobstructive HCM and those who had septal hyper-
trophy secondary to any other underlying cause were
excluded. In addition, we excluded patients with
Shone syndrome or atrioventricular canal defect
with concomitant SAS. Thus, the final study groups
included 152 patients with HCM and 63 patients with
congenital SAS.
CLINICAL DATA. Clinical information included age,
height, weight, body surface area, and body mass
index at the time of surgery as well as symptoms
such as shortness of breath, chest pain, presyncope, and
syncope. Data on preoperative dysrhythmias included
the need for implantable cardioverter-defibrillator (ICD),
pacemaker, history of radiofrequency ablation, and
cardiac arrest. Postoperative need for ICD placement
within 30 days after surgical procedure was noted.
Results of any genetic testing and family history of
HCM or SAS were obtained from the patient’s medical
history.
IMAGING AND HEMODYNAMIC DATA. Transthoracic echo-
cardiographic examination reports were generally
available in patients after November 1974. Hemody-
namic information from cardiac catheterization was
included for patients treated between August 1963 and
November 1974. Maximum instantaneous left ventricu-
lar (LV) outflow tract gradients were obtained at rest
with continuous wave Doppler echocardiography. In
some patients who may not have had a large resting
gradient, provocative maneuvers (Valsalva maneuver,
amyl nitrite inhalation, or exercise) may have been used
to elicit a gradient. Preoperative ejection fraction, LV
mass index, and wall thickness were determined as
previously described.6 Information on mitral valve
systolic anterior motion (SAM) was obtained from
preoperative transthoracic and intraoperative
transesophageal echocardiograms.
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FATIMA ET AL 137
OUTCOMES OF OPERATION FOR LVOT OBSTRUCTION
SURGICAL DATA. For patients with obstructive HCM,
transaortic septal myectomy was performed as previ-
ously described.7 Transaortic membranectomy was
supplemented by shallow septal myectomy in 36
patients (57%).8 Additional procedures are detailed in
Supplemental Table 1.
FOLLOW-UP DATA. The last clinical follow-up was
collected from the medical record to assess
reoperation. Mortality data were supplemented with
information from the national death and location
database (Accurint). Assuming a small lag in data,
January 31, 2020, was used as the date of last vital
status for those accurately matched to the national
database and still assumed to be alive.
STATISTICAL METHODS. Categorical data were compared
with the c2 test. Most continuous variables were not
normally distributed and therefore are reported as me-
dian and interquartile range, and groups were compared
with Wilcoxon rank sum test. We used the Kaplan-Meier
method to estimate survival. We analyzed occurrence of
all reoperations as well as procedures related to
recurrent subaortic LVOTO. We provided a summary of
these reoperations along with estimated cumulative
incidence with death as a competing risk. Univariable
proportional regression models were used to
investigate the association of morphologic features,
surgical procedure type, and diagnosis with survival
and the need for reoperation (event-specific regression
model). Because of the age differences between the
groups, we reweighted the data to the empirical age
distribution of our cohort and repeated the reoperation
analyses on the weighted data set.
RESULTS
At the time of presentation for initial repair, patients
with HCM were older than patients with SAS (15 [10-19]
years vs 8 [5-13] years; P < .001). Patients with HCM
had higher body mass index than SAS patients (21.4
[17.3-26.1] kg/m2 vs 18.2 [15.4-23.0] kg/m2; P < .001).
Patients with HCM were more symptomatic with dys-
pnea (64% vs 35.6%; P < .001), chest pain (44% vs
20.7%; P ¼ .002), and presyncope/syncope (26.7% vs
8.6%; P ¼ .005) compared with those with SAS (Table 1).
Of the patients with HCM, 2% (n ¼ 3) had cardiac ar-
rest before operation, and 15% (n ¼ 23) had ICD im-
plantation; none of the SAS patients had a history of
cardiac arrest and only 2% (n ¼ 1) had an ICD. A pace-
maker was placed preoperatively in 2% (n ¼ 3) of pa-
tients in the HCM group vs 2% (n ¼ 1) in the SAS group.
A family history of the disease was noted in 36% of
patients with HCM, and 4% of HCM patients had a
family history of sudden cardiac death. In the SAS group,
5% (n ¼ 3) had a family history consistent with HCM but
138 FATIMA ET AL Ann Thorac Surg
OUTCOMES OF OPERATION FOR LVOT OBSTRUCTION 2023;115:136-43

TABLE 1 Baseline Characteristics of Patients With HCM and Congenital SAS T ABLE 2 Preoperative Echocardiographic Parameters
Undergoing Operation for Relief of LVOTO of Patients With HCM and Congenital SAS Undergoing
Operation for Relief of LVOTO
HCM SAS
Characteristic (n ¼ 152) (n ¼ 63) P Value Preoperative
Age at surgery, y 15.2 (9.6-18.8) 7.7 (5.2-13.3) <.001a Echocardiographic
Parameter HCM (n ¼ 152) SAS (n ¼ 63) P Value
Height, cm 161.3 (136.7-173.2) 122.0 (103.5-153.9) <.001a
Septal thickness, 23 (17-30) 10 (8-16) <.001a
Weight, kg 58.0 (32.4-74.0) 26.0 (18.1-52.8) <.001 a
diastole, mm
Body surface area, m 2
1.6 (1.1-1.9) 0.9 (0.7-1.5) <.001 a
N-Miss 16 20
Body mass index, kg/m2 21.4 (17.3-26.1) 18.2 (15.4-23.0) <.001a
LV wall thickness, 13 (10-17) 10 (8-12) <.001a
Dyspnea <.001 b
diastole, mm
Yes 96 (64.0) 21 (35.6) N-Miss 17 20
N-Miss 2 4 LV mass index, g/m2 215 (157-289) 108 (92-154) <.001a
Syncope/presyncope .005b N-Miss 51 30
Yes 40 (26.7) 5 (8.6) Ejection fraction, % 75 (70-79) 72 (68-75) .002a
N-Miss 2 5 N-Miss 30 22
Chest pain .002b LVOT peak 92 (77-117) 100 (76-110) .950a
Yes 66 (44.0) 12 (20.7) gradient, mm Hg
N-Miss 2 5 N-Miss 37 26
Family history of HCM 55 (36.2) 3 (4.8) <.001b SAM <.001b
Family history of sudden 6 (3.9) 1 (1.6) Yes 137 (100.0) 6 (12.2)
cardiac death No 0 (0.0) 43 (87.8)
Family history unknown 3 (2.0) 2 (3.2) N-Miss 15 14
No family history of HCM 88 (57.9) 57 (90.5)
Genetic testing .078b a
Kruskal-Wallis rank sum test; bPearson c2 test. Categorical variables are
presented as number (percentage). Continuous variables are presented as
Not performed 125 62
median (interquartile range). HCM, hypertrophic cardiomyopathy; LV, left
Positive result 21 (77.8) 0 (0.0) ventricular; LVOTO, left ventricular outflow tract obstruction; N-Miss, number of
Negative result 6 (22.2) 1 (100.0) missing values; SAM, systolic anterior motion; SAS, subaortic stenosis.

Pacemaker before surgery .015b

ICD 23 (15.1) 1 (1.6)
Pacemaker 3 (2.0) 1 (1.6)
No 126 (82.9) 61 (96.8) There was no operative mortality in the SAS group.
History of radiofrequency ablation 2 (1.3) 0 (0.0) .360b Two operative deaths (1.3%) in the HCM group occurred
Preoperative history of 3 (1.95) 0 (0.0) .261b in patients with severe biventricular obstruction. One
cardiac arrest
14-month-old boy died 1 week after hospitalization for
a
Wilcoxon rank sum test; Pearson c test. Categorical variables are presented as number (percentage).
b 2 biventricular myectomy in 1982, and another 4-year-old
Continuous variables are presented as median (interquartile range). HCM, hypertrophic cardiomyopathy; ICD, boy died of low cardiac output 1 day after operation
implantable cardioverter-defibrillator; LVOTO, left ventricular outflow tract obstruction; N-Miss, number of
missing values; SAS, subaortic stenosis. in 1994.
The median postoperative follow-up duration
(reverse Kaplan-Meier) was 13 years (interquartile range,
were categorized as SAS because of intraoperative evi-
dence of a discrete subaortic membrane distinct from
the septal contact lesion seen in obstructive HCM.
Seventeen percent (n ¼ 27) of patients with HCM un-
derwent genetic testing, the result of which was positive
in 78% (n ¼ 21). Only 1 patient with SAS underwent ge-
netic testing for HCM, and the result was negative.
As seen in Table 2, preoperative echocardiographic
studies demonstrated preserved ejection fraction in
both HCM and SAS groups. Septal thickness was
greater in HCM patients (23 [17-30] mm) compared
with the SAS group (10 [8-16] mm; P < .001). Also, values
for posterior wall thickness and LV mass index were
significantly greater in the HCM group. All patients with
obstructive HCM had associated SAM. On Doppler
FIGURE 1 Survival of patients with hypertrophic car-
echocardiography, the maximum instantaneous LV diomyopathy (HCM) and congenital subaortic stenosis
outflow tract gradient was 92 (77-117) mm Hg for patients (SAS) after undergoing surgical correction of left ven-
with HCM and 100 (76-110) mm Hg for the SAS group tricular outflow tract obstruction.

(P ¼ .95).

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Ann Thorac Surg FATIMA ET AL 139
2023;115:136-43 OUTCOMES OF OPERATION FOR LVOT OBSTRUCTION

F I G U R E 2 ( A ) Ris k of r eop e r at i o n ( R e o p ) for an y c a rd ia c s u rge r y proc e d u re i n pa t ie n ts w i th h ype r tr o p h ic c ar d i o my o p at h y

( H C M ) an d c o nge n i ta l s ub ao r ti c ste n o si s (S AS ) af te r u n d e r goi ng su r g ic a l c o rr e ct i o n ( u n w ei g h t e d ) . (B ) R i s k o f r e o p er a t i o n fo r
an y c ar d i a c su r g e ry pr o c ed ur e in p a ti e n ts w i th H C M an d c o ng e n i ta l S A S a ft er u nd er g o i ng su r g i ca l c o r re c ti o n (we i g h te d ) .

1.1-20.5), and patients with SAS had better long-term
survival compared with those with HCM (P ¼ .007). As
seen in Figure 1 and Supplemental Table 2, survival of
the 2 groups was similar through the first 10 years
postoperatively; but during the second decade of
follow-up, HCM patients had poorer survival (20-year
survival of 80% for HCM vs 91% for SAS). In the uni-
variable proportional hazard model, overall mortality in
the SAS group was lower (hazard ratio [HR], 0.26; 95%
CI, 0.09-0.74; P ¼ .012). Age at operation was not asso-
ciated with survival in this young cohort.
During follow-up, the 20-year cumulative risk of
reoperation for any cause was 26% (95% CI, 16%-42%)
for patients with HCM and 52% (37%-72%) for patients
with SAS (P ¼ .001; Figure 2A; Supplemental Table 3).
This risk of reoperation for any cause was 3 times
higher in the SAS group compared with the HCM group
(HR, 3.13; 95% CI, 1.56-6.26; P ¼ .001; Supplemental
Table 5).
In the HCM group, 11 patients required reoperation for
recurrent or residual LVOTO a median of 11 years after
initial surgery, and 1 patient underwent an additional
procedure 3 years after the second operation. In the SAS
group, 15 patients required reoperation at a median of 7
years after the initial procedure; of those, 3 patients
required a second reoperation after a median duration of
11 years from the second operation. Ten years after
initial repair, incidence of reoperation for recurrent
LVOTO was 5% (2%-13%) in patients with HCM and 31%
(19%-50%) in those with SAS (Figure 3A; Supplemental
Table 4).
In the SAS group, the addition of a septal myectomy
at the time of initial membranectomy did not influence
the risk of reoperation. As seen in Table 3, older age of
the patient was significantly associated with lower risk
of reoperation due to recurrent obstruction (HR, 0.87
for each year; 95% CI, 0.81-0.94; P < .001). This was
also true when each group was analyzed separately
(HCM: HR for each year, 0.90 [95% CI, 0.82-1.00; P ¼
.041]; SAS: HR for each year, 0.84 [95% CI, 0.71-0.99;
P ¼ .033]). To account for the association of age and
reoperation and the significant age difference between
groups, the cohort was inverse probability weighted on
the basis of the empirical age distribution of the cohort
(Figures 2B and 3B). In this age-weighted analysis, the
effect of the SAS group on risk (vs HCM) of reoperation
for recurrent LVOTO was attenuated from 3.06 (95% CI,
1.40-6.67; P ¼ .005) to 1.80 (95% CI, 0.78-4.18; P ¼ .179).
COMMENT
This study examines potential differences in clinical
presentation and long-term outcomes of young patients
with SAS and HCM undergoing LVOTO resection. We
found that patients with HCM were more symptomatic
and presented with LVOTO at an older age compared
with the SAS group. The risk of reoperation due to
recurrent LVOTO was 3 times higher in patients with SAS
than in those with HCM. However, despite the increased
need for reoperation due to recurrent LVOTO in the SAS
group, the late survival of young patients with HCM was
poorer than that of those with membranous SAS. The
cause of this decrease in survival among young patients
with HCM is likely to be risk of arrhythmias and predi-
lection for development of restrictive physiology.
To date, there are no studies in the pediatric popu-
lation that compare the symptomatic presentation and
outcomes of patients with HCM and SAS. Etnel and co-
workers9 in 2015 published a meta-analysis on outcomes
of pediatric patients with SAS. The authors included 24
studies, and of these, 16 reports documented that the
pooled total incidence of reoperation was 2.04% per

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140 FATIMA ET AL Ann Thorac Surg
OUTCOMES OF OPERATION FOR LVOT OBSTRUCTION 2023;115:136-43

FIGURE 3 (A) Reoperation (Reop) for recurrent or residual left ventricular outflow tract obstruction in patients with hy-
pertrophic cardiomyopathy (HCM) and congenital subaortic stenosis (SAS) after undergoing surgical correction (un-
weighted). (B) Reoperation for recurrent or residual left ventricular outflow tract obstruction in patients with HCM and
congenital SAS after undergoing surgical correction (weighted).

year, which correlates with our findings of 52% during
20 years, resulting in an average 2.6% every year.9 In the
same meta-analysis, pooled risk of mortality was 0.12%
per year, but these data include the natural history of
patients who were not operated on.9 Another study by
Zhu and associates10 in 2020 reported the outcomes of
pediatric patients with obstructive
underwent septal myectomy. Inferences are limited by
the relatively short follow-up (median, 3.2 years), but
overall freedom from reoperation was 98% at 3 years,
and overall survival was 96.5% in 3 years.10 Our results
are generally similar with a 3.5% risk of reoperation
and survival of 95.6% at 5 years after operation for the
HCM group.
We found important differences in the clinical char-
acteristics of young patients with SAS and those with
obstructive HCM. Patients with HCM were older at the
time of surgery to relieve LVOTO and, as expected, had
greater height and weight. Although hemodynamics
including LV outflow tract gradient and LV ejection
fraction were not significantly different between the
groups, patients with HCM more frequently presented
with dyspnea, chest pain, and history of presyncope and
syncope. Patients with HCM had significantly greater LV
wall thickness, LV septal thickness, and LV mass index
compared with the SAS group. Although these differ-
ences might be expected because of differences in body
HCM who size, greater degrees of hypertrophy in patients with
obstructive HCM are likely to be due to the underlying
disease. LV hypertrophy in patients with SAS is sec-
ondary to obstruction caused by the membrane, whereas
hypertrophy in patients with obstructive HCM is largely
related to the underlying cardiomyopathy.
Some clinical and hemodynamic features of obstruc-
tive HCM and SAS may overlap, and in rare instances,
both conditions may be present in the same patient.11,12
In our series, 1 patient with a documented family history
of HCM was found intraoperatively to have a typical
subaortic membrane distinct from the contact lesion on
the septum that results from SAM of the mitral leaflets.
Another patient who was clinically described as having
HCM was discovered to have an unusual extension of

TABLE 3 Univariable Proportional Hazard Model Predicting the Cause-Specific Hazard Ratio for Late Reoperation in
Patients With HCM and Congenital SAS Related to Recurrent or Residual LVOTO

Unweighted Age Weighted

Variable HR Lower 95% CI Upper 95% CI P Value HR Lower 95% CI Upper 95% CI P Value

Diagnosis, SAS vs HCM 3.055 1.399 6.669 .005 1.802 0.777 4.178 .170
Older age at surgery (per year) 0.874 0.811 0.943 <.001 0.881 0.811 0.956 .002
Greater height (per cm) 0.976 0.964 0.988 <.001 0.978 0.966 0.990 <.001
Greater weight (per kg) 0.959 0.937 0.982 <.001 0.960 0.938 0.983 <.001
Higher body mass index (per kg/m2) 0.897 0.818 0.982 .019 0.870 0.782 0.967 .010
Septal myectomy in SAS patients 0.991 0.279 3.518 .989 0.667 0.184 2.415 .537
Membranectomy in SAS patients 1.322 0.451 3.878 .611 1.007 0.305 3.325 .990

HCM, hypertrophic cardiomyopathy; HR, hazard ratio; LVOTO, left ventricular outflow tract obstruction; SAS, subaortic stenosis.

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Ann Thorac Surg
2023;115:136-43
the membrane involving the anterior leaflet of the mitral
valve and the ventricular aspects of the left and
noncoronary cusp, findings typical of SAS. As a general
clinical rule, patients with SAS have hemodynamic
features of fixed obstruction and no SAM of the mitral
valve. In this study, however, we recognized 6 patients
(9.5%) who had SAM associated with a discrete
membrane characteristic of SAS. Iwata and colleagues13
in 2008 described a similar unusual patient with SAS
associated with SAM of the mitral valve who had, in
addition, an anterior cleft in the mitral leaflet and an
accessory papillary muscle.
Although perioperative mortality was similar for the
patients in the SAS and HCM groups, late survival of
patients with HCM was reduced. Unfortunately, data on
causes of death were incomplete in our study, but Nor-
rish and Kaski14 reported that beyond infancy, sudden
cardiac death is the most common cause of death in
pediatric patients with HCM; arrhythmias account for
>50% of adverse events occurring within 10 years of
diagnosis. Of note, this study did not include patients
who had surgical correction for obstructive HCM.14 Zhu
and associates10 documented an overall 2.6% incidence
of sudden cardiac death after surgical correction of
HCM in a median follow-up period of 3.2 years,
emphasizing the importance of risk stratification for ICD
in children with HCM regardless of prior septal myec-
tomy. More recently, Hughes and colleagues15 reported
that myocardial perfusion is impaired in patients who
are genotype positive for HCM, even in the absence of
hypertrophy and scarring, and resulting ischemia may
predispose the patient to major adverse cardiac events.
In our study, relief of LVOTO was late in HCM patients
compared with SAS patients, and it is possible that this
too increases the risk of underlying fibrosis and
concern of ischemia secondary to LV hypertrophy and
subsequent diastolic dysfunction.
The incidence of reoperation for any cause was 3
times higher for patients with SAS than for those with
HCM. It is notable, too, that the incidence of reoperation
for recurrent LVOTO after corrective surgery was also 3
times higher in the SAS group. It appears, however, that
some of this difference was related to younger age at the
time of initial corrective surgery. In our cohort, the
addition of septal myectomy at the time of mem-
branectomy did not appear to decrease the risk of
reoperation, and this is similar to the reports of Mazurek
and coworkers,16 Karamlou and coworkers,17 and van
der Linde and coworkers.5 Others have hypothesized
that the addition of septal myectomy reduces the risk
of reoperation. Lupinetti and colleagues18 suggested
that performing myectomy reduces turbulence, which
may discourage progressive scar formation in the
subvalvular area during healing; thus, performing a
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FATIMA ET AL 141
OUTCOMES OF OPERATION FOR LVOT OBSTRUCTION
myectomy would eliminate the substrate for recurrent
subvalvular stenosis. Similarly, Brauner and
colleagues19 hypothesized that turbulence caused by
incomplete removal of LVOTO promotes fibrosis and
subsequent restenosis, and septal myectomy can
reduce obstruction and therefore will decrease
recurrence. The rationale behind performing a septal
myectomy is based on the pathologic process of SAS, a
progressive lesion characterized by thickening, fibrosis,
and scarring of the LVOT.16
In our study, the need for reoperation due to recurrence
of SAS was 1.8 times higher after 5 years and 6.2 times
higher after 10 years of index surgery compared with the
HCM group. Several studies have identified risk factors for
reoperation, including age <2 years at first intervention,
postoperative gradient >20 mm Hg, presence of a hypo-
plastic aortic annulus, <5-mm distance of membrane to
aortic valve, and associated left-sided heart lesions.20,21
Ramog
lu and coworkers22 recognized a higher risk of
reoperation in isolated SAS but similar risk in
membranous and fibromuscular types. Early surgical
procedure may be beneficial in preventing aortic
insufficiency but does not affect the rate of reoperation.22
This study has several limitations including the
possible bias associated with a single-center retrospec-
tive investigation. As reoperation was an important
variable of the study, we had limited access to data for
the patients who underwent index surgery in other in-
stitutions, and therefore these patients were excluded
from the study. The study patients were identified
during a long period during which surgical and diag-
nostic techniques have improved; it is unclear, however,
whether current imaging techniques for surveillance
would improve late results. Last, our institution receives
patients from a global referral base, and detailed follow-
up in many was not possible.
In summary, among patients
21 years of age with
obstructive HCM and SAS undergoing corrective surgery,
those with HCM were older and more symptomatic
preoperatively compared with those with SAS, but the
severity of LVOTO was similar between the groups. The
greater prevalence and severity of symptoms in those
with HCM may be related to underlying myocardial
disease and diastolic dysfunction or to SAM of the mitral
valve causing variable degrees of regurgitation. Despite
a higher incidence of later reoperation, survival of pa-
tients with LVOTO due to SAS was superior to that of
patients with HCM.
FUNDING SOURCES
This work was supported by the Paul & Ruby Tsai Family.
DISCLOSURES
The authors have no conflicts of interest to disclose.
142 FATIMA ET AL
OUTCOMES OF OPERATION FOR LVOT OBSTRUCTION
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ª 2023 by The Society of Thoracic Surgeons
Published by Elsevier Inc.
Obstruction on the Left Can Be Hard
to Make Right
INVITED COMMENTARY:
In this issue of The Annals of Thoracic Surgery, the nicely
1
prepared article by Fatima and colleagues describes a
retrospective review of patients aged less than 21 years
who had surgery for hypertrophic cardiomyopathy
(HCM) or subaortic stenosis (SAS) at Mayo Clinic over
the last 6 decades. They found that patients with HCM
were older and more symptomatic than patients with
SAS. Thirty-day mortality was slightly higher in the
HCM group, but survival was similar through the first 10
years. However, during the second decade, patients with
HCM had worse survival. They also found that at 10 and
20 years after repair, more patients with SAS required
Downloaded for Anonymous User (n/a) at Egyptian Knowledge Bank from ClinicalKey.com by Elsevier on June 01,
2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
Ann Thorac Surg
2023;115:136-43
11. Anderson MJ, Arruda-Olson A, Gersh B, Geske J. Subaortic
membrane mimicking hypertrophic cardiomyopathy. BMJ Case Rep.
2015;2015:bcr2015212321. https://doi.org/10.1136/bcr-2015-212321
12. Mushtaque RS, Mushtaque R, Baloch S. Co-existing subaortic stenosis
in a patient with hypertrophic obstructive cardiomyopathy: a rare and
interesting finding. Cureus. 2020;12:e11891.
13. Iwata Y, Imai Y, Shin’oka T, Kurosawa H. Subaortic stenosis associated
with systolic anterior motion. Heart Vessels. 2008;23:436-439.
14. Norrish G, Kaski JP. The risk of sudden death in children with hyper-
trophic cardiomyopathy. Heart Fail Clin. 2022;18:9-18.
15. Hughes RK, Camaioni C, Augusto JB, et al. Myocardial perfusion de-
fects in hypertrophic cardiomyopathy mutation carriers. J Am Heart Assoc.
2021;10:e020227.
16. Mazurek AA, Yu S, Lowery R, Ohye RG. Routine septal myectomy
during subaortic stenosis membrane resection: effect on recurrence rates.
Pediatr Cardiol. 2018;39:1627-1634.
17. Karamlou T, Gurofsky R, Bojcevski A, et al. Prevalence and associated
risk factors for intervention in 313 children with subaortic stenosis. Ann
Thorac Surg. 2007;84:900-906 [discussion: 906].
18. Lupinetti FM, Pridjian AK, Callow LB, Crowley DC, Beekman RH,
Bove EL. Optimum treatment of discrete subaortic stenosis. Ann Thorac
Surg. 1992;54:467-470 [discussion: 470-471].
19. Brauner R, Laks H, Drinkwater DC Jr, Shvarts O, Eghbali K, Galindo A.
Benefits of early surgical repair in fixed subaortic stenosis. J Am Coll Car-
diol. 1997;30:1835-1842.
20. Carlson L, Pickard S, Gauvreau K, et al. Preoperative factors that pre-
dict recurrence after repair of discrete subaortic stenosis. Ann Thorac Surg.
2021;111:1613-1619.
 T, et al. Paediatric subaortic stenosis:
21. De Wolf R, François K, Bove
long-term outcome and risk factors for reoperation. Interact Cardiovasc
Thorac Surg. 2021;33:588-596.
22. Ramog
lu MG, Karago € zlu
€ S, Uçar T, et al. Long-term follow-up of sub-
valvular aortic stenosis in children: a single-centre experience. Cardiol
Young. 2022;32:980-987.
0003-4975/$36.00
https://doi.org/10.1016/j.athoracsur.2022.09.004
reoperation for recurrent left ventricular outflow tract
obstruction. This is the first paper directly comparing the
differences between these two pathologies in young
patients. It is a good-size cohort from a leading institu-
tion in HCM surgery. The manuscript is well written, the
data clearly presented, and the discussion appropriately
contextualizes the results without overstatement.
Although well addressed by the authors, this study
has limitations. The 2011 North American guidelines
consider septal myectomy as the gold standard tech-
nique for septal reduction2; however, the operation is
notoriously challenging and operative outcomes vary
dramatically based on experience.3 The Mayo
experience in HCM treatment is one of the largest in
the world, so their outcomes may not be
representative of HCM treatment at lower volume