Reference number to be mentioned by correspondence : CH/ref.

n° 4275-SANSONE-

Acta Chir Belg, 2011, 111, 000-000

The Actis-Gouge : a Simple Cutting Tool for Proper Muscular Resection in

Hypertrophic Cardiomyopathy
F. Sansone, G. M. Actis Dato, E. Zingarelli, R. Flocco, G. Punta, P. G. Forsennati, F. Parisi, G. Bardi, S. del Ponte,
R. Casabona
Division of Cardiac Surgery, Mauriziano Umberto I Hospital, Turin, Italy.

Abstract. Background : Surgical treatment of hypertrophic cardiomyopathy (HC) may be challenging for the risk of
surgical complications or insufficient resection. We present our cutting tool to perform proper muscular resection in HC.
Material and methods : Ten patients (5 males, mean age 43,1 ± 19,6 years, range 9-70 years) were operated on for HC
using this semicircular cutting device. Combined procedures were : mitral valve repair (n = 1), mitral valve replacement
(n = 2), right ventricular myectomy (n = 1), aortic valve replacement (n = 1), mitral and aortic replacement (n = 1).
Results : There was one early death. All the surviving patients are alive over a variable follow up from 2 to 8 years, with
consistent reduction of symptoms : in fact, no one patient had residual angina with significant reduction of the NYHA
class from 3,2 ± 0,6 to 1,3 ± 0,5 postoperatively (p < 0,05). Muscular resection was effective with significant reduction
of sub-valvular gradient from 84.5 + 33,4 mmHg to 14,1 ± 17,6 mmHg (p < 0,05) without complications as complete
atrio-ventricular block or ventricular septal defects.
Conclusion : Our semicircular myotome is an effective tool to perform a safe myectomy and it avoids surgical
complications as atrio-ventricular blocks or sub-valvular injuries. Our experience suggests that this cutting tool offers a
reproducible method for muscular resection and it shows appreciable effects in the reduction of sub-valvular gradient
with promising results in terms of morbidity and mortality.

Introduction Symptoms were : angina (6 patients), dyspnea

(10 patients), arrhythmias (3 patients), syncope and
Hypertrophic obstructive cardiomyopathy (HC), usually dizziness (2 patients). NYHA functional class was III in
called idiopathic hypertrophic sub aortic stenosis (1) or 7 cases and IV in 3.
muscular sub aortic stenosis (2), induces significant left A marked left ventricular hypertrophy was detected
ventricular outflow obstruction with a variable progres- by electrocardiography in all patients and two of them
sion of the left ventricular dysfunction (3-4) and a poor presented with left bundle branch block.
long term prognosis (5). (…) Surgical myectomy Preoperative sub-valvular gradient was 84,5 ±
(Morrow procedure) is the gold standard of care for 33,4 mmHg (Table II). All the surviving patients were
patients affected by drug-refractory HC and the com- assessed by trans-thoracic echocardiography before hos-
bined procedures (as mitral valve surgery) did not wors- pital discharge in order to check the improvement of the
en the postoperative outcome (6). HC disarranges the left obstruction and the morphology of the residual septum.
ventricular anatomy and the surgical treatment must not
be limited to the interventricular septum, involving other Surgical technique and description of the device
intra-ventricular sites such as the mitral subvalvular
All the patients were operated on through median ster-
apparatus or the chordae tendineae. However, the use of
notomy and the extra-corporeal circulation was estab-
a dedicated device that allows a reproducible and safe
lished between the ascending aorta or femoral artery and
myectomy may be of interest and we present our expe-
the right atrium. Systemic anticoagulation was achieved
rience with this new cutting tool, called the Actis gouge.
by 300 UI/Kg of heparin and myocardial protection was
obtained by cold crystalloid cardioplegia in 7 patients
Material and method
and blood cardioplegia in 3 patients. The aortic valve
was then exposed through oblique aortotomy (approxi-
mately 2 cm above the sino-tubular junction) : the valve
Patients’ characteristics (Table I)
was carefully evaluated to check the morphology of the
10 patients were operated on for HC (5 males, mean age cusps that were gently attached to the aortic wall by a 6/0
43,1 ± 19,6 yrs, range 9-70 years) using this new cutting prolene stitch. The hypertrophic septum was then identi-
tool. fied just below the commissure between the right and left
2 F. Sansone et al.

Table I symptoms. NYHA class was reduced from 3,2 ± 0,6 to

Preoperative data 1,3 ± 0,5 postoperatively (p < 0,05) (Table II). No one
N sex age Ang dysp ar syn BBB patient had syncopes over the follow up period and the
1 F 39 0 1 1 0 1 ECG showed a reduction of the myocardial hypertrophy,
2 M 42 1 1 0 0 0 where present.
3 M 39 1 1 0 1 0
4 F 9 0 1 0 0 0 Discussion
5 M 27 1 1 1 0 0
6 M 59 1 1 1 1 1 HC represents a misdiagnosed pathology and many
7 F 25 1 1 0 0 0 patients continue to be symptomatic because of this
8 F 70 0 1 0 0 0 disease when not accurately treated.
9 F 54 0 1 0 0 0 The causes of HC are not well known : for many years
10 M 67 0 1 0 0 0 the systolic anterior motion (SAM) was considered as a
Legend : ang = angina ; dysp = dyspnea ; ar = arrhytmias ; syn = consequence of the Venturi effect, a local negative pres-
syncope ; BBB = bundle branch block. sure that may stretch the anterior leaflet toward the sep-
tum. Whereby the objective of the surgical resection was
limited to the enlargement of the outflow tract, to reduce
cusps and anchored with a prolene 0 stitch with n° 30 the Venturi forces. However, this approach may fail,
needle (Fig. 2). The myotomy was performed by the use since the Venturi effect and the septal hypertrophy are
of this new cutting tool (Fig. 3a-b) that is a scalpel with not alone in the etiology of the SAM (4) and many other
a semicircular cut line and with a round handle kurled. causes are involved. The variable degree and distribution
Three are the sizes of the myotome (10-12-14 mm of of the left ventricular hypertrophy needs a meticulous
radius) with different depth of resection, from about muscular resection because the hypertrophy is not con-
8 mm up to 15 mm. fined to the septal myocardium but includes the muscu-
Pulling on the wire, the cut is performed using gentle lar or fibrous structures that connect the papillary mus-
pressure and rotation on its axis by the hand of the sur- cles to the ventricular septum or free wall. A careful
geon. The resection was then extended into the ventricu- analysis of these structures must be carried out during
lar cavity for 3-4 cm in length, leaving a smooth surface. the myectomy to remove the intraventricular obstruction
The septal myotomy is often not enough treatment of the and to leave the tip of the papillary muscle free from con-
the muscular or fibrous structures connecting the papil- tact with the ventricular wall. Also, anomalous chordae
lary muscle to the ventricular septum or free wall. Indeed or fibrous attachments of the mitral leaflets to the septum
all these structures were removed in order to leave the tip or free wall need to be routinely excised or divided. Only
of the papillary muscle free from contact with the a complete and extensive treatment both of the inter-
ventricular wall. Also, anomalous chordae or fibrous ventricular septum and the left ventricular structures may
attachments of the mitral leaflets to the septum or free achieve interesting results (7-11).
wall were excised or divided. Other procedures were However, the surgery to relieve obstruction in HC can
then performed after the muscular resection. be technically very challenging for several reasons. In
fact, since the access is through the aortotomy and the
Results exposure of the septal bulge is limited, the resection could
be inadequate for the insufficient or excessive extension
There was 1 in hospital death. Subvalvular gradient in depth and length, with persistent obstruction (12), ven-
decreased from 84,5 ± 33,4 mmHg to 14,1 ± 17,6 mmHg tricular septal defect or complete atrio-ventricular block.
(p < 0,05). No one patient had complete atrio-ventricular Ventricular septal defect has been reported in 0% to 2%
block that required pacemaker implantation. No major of reports from 1987 to 1996 (13) and higher (6%) in the
complications as ventricular septal defect or mitral elderly (14). For these reasons, surgery for HC has been
regurgitation were recorded. concentrated in a few centers which have accumulated a
Over a mean follow up of 6,0 ± 3,2 years, all surviv- large experience. The results are superior compared to
ing patients are alive without residual angina or other centers with limited experience.

Table II
Results : reduction of mean NYHA functional class and mean transaortic gradient
Preoperative NYHA Postoperative NYHA p Preoperative gradient Postoperative gradient p
mmHg mmHg
3,2 ± 0,6 1,3 ± 0,5 < 0,05 84.5 ± 33,4 14,1 ± 17,6 0,05
Semicircular Myotome in Hypertrophic Cardiomyopathy 3

a b

Fig. 3a-b
Demonstration on an anatomical heart of the use of semicircu-
lar myotome. a. Anchorage of the myocardium with a prolene
0 stitch, pulling on it (arrow) facilitates the resection of the
required myocardium. b. Anatomical part removed and widen-
ing of the outflow tract area. The surface is smooth and regular
after myocardial resection.

Fig. 1
Different sizes of the semicircular myotome that allow a Although trans-aortic approach is less invasive, the poor
variable entity of the muscular resection. exposure may impair surgical results (18-21) and the risk
of aortic cusps injuries is considerable. To overcome
these drawbacks, we developed a simple cutting tool that
may be used for trans-aortic myectomy (Fig. 1). The
advantages are :
– proper muscular avoiding excessive or insufficient
myectomy and the related complications ;
– myocardial surface is usually smooth and uniform,
thus avoiding the possibility of fragmentation with the
potential risk of embolization or thrombosis ;
– its use is very simple and the cost limited (22).
We think that an effective treatment of HC must consid-
er nowadays a careful evaluation of the intra-ventricular
structures, as papillary muscles, mitral chordae and sub-
valvular apparatus since the isolated myectomy of the
inter-ventricular septum cannot remove the obstruction
and is ineffective for the treatment of HC.
The aim of our experience is to present a simple
cutting tool to obtain an effective myectomy, since the
use of a standard scalpel may induce aortic valve
Fig. 2
Hypertrophic septum just between the two coronary cusps of damages and inadequate resection. Our device, with the
the aortic valve (hatched area). The asterisks indicates the point sharp surface only in the bottom edge, prevents any
of applying traction. injury of the aortic valve.

Conclusion
At the beginning, surgical treatment was the myecto-
my of the hypertrophic septum (15-17), located just We recommend a careful evaluation of the left ventricu-
below the right aortic cusp. Recently, the idea of a com- lar structures before surgery, to allow a satisfactory and
plete reconstruction of the LV outflow tract, induces to definitive treatment for obstruction in HC. The isolated
extend the surgical resection into the left ventricle, by the muscular resection of the septum does not achieve symp-
resection of structures previously not considered. toms disappearance and may induce an unsatisfactory
4 F. Sansone et al.

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