Combined cox maze procedure, septal myectomy, and mitral valve replacement for severe hypertrophic obstructive cardiomyopathy complicated by chronic atrial fibrillation.

Atrial fibrillation (AF) has been reported to be an important prognostic indicator for clinical deterioration particularly in patients with hypertrophic obstructive cardiomyopathy (HOCM). A 66-year-old female complained of severe exertional dyspnea and tachycardia, which were resistant to medical treatments. Doppler echocardiography demonstrated a peak left ventricular outflow tract (LVOT) gradient of 117 mmHg at rest. A catheter examination revealed left ventricular end diastolic pressure of 34 mmHg, a cardiac index of 1.94 L/minute/m(2), and a peak LVOT gradient of 70 mmHg at rest. A transaortic septal myotomy/myectomy was performed first, and Cox maze III procedure was performed through the right and left atrium followed by mitral valve replacement. The patient recovered dramatically except for temporary complete atrioventricular block. One year after operation, the patient is doing well with sinus rhythm and the echocardiogram revealed a peak LVOT pressure gradient of 7.6 mmHg at rest. This surgical approach might be recommended for the treatment of AF in HOCM. (Ann Thorac Cardiovasc Surg 2003; 9: 323-5)