Septal myectomy is a surgical procedure performed to reduce the muscle thickening that occurs in patients with hypertrophic cardiomyopathy (HCM). Septal myectomy is one treatment option for HCM when symptoms persist despite optimal treatment with medications, or if obstruction severely restricts blood ejection from the heart.
During the septal myectomy procedure, the surgeon removes a small amount of the thickened septal wall to widen the outflow tract from the left ventricle to the aorta. This eliminates the obstruction and the mitral valve regurgitation that occurs with this condition. Patients often experience rapid relief of symptoms after the procedure.
During the septal myectomy procedure, the surgeon removes a small amount of the thickened septal wall to widen the outflow tract from the left ventricle to the aorta.
Who is eligible for the myectomy procedure?
Patients with a diagnosis of hypertrophic cardiomyopathy should be assessed at an experienced center to determine the severity of their condition and to develop a treatment plan.
It is estimated that obstruction occurs in more than 70 percent of patients with HCM. The severity of obstruction, symptoms and the patient’s response to medications vary greatly. Many patients have no symptoms or mild obstruction and can be treated with medications like beta blockers or calcium channel blockers.
Septal myectomy is the safest, most successful and most durable procedure for patients with severe symptoms or severe obstruction. Elderly patients or those with advanced medical conditions may be better served by percutaneous alcohol septal reduction.
Hypertrophic cardiomyopathy (HCM) is a complex type of heart disease associated with a thickening of the heart muscle, most commonly at the septum (the muscular wall that separates the left and right side of the heart), just below the aortic valve. If the septum becomes too thick, the passageway to the aorta becomes very narrow, limiting or blocking the flow of blood from the left ventricle to the aorta, called “outflow tract obstruction.” The septal thickening that results in obstruction varies from a few millimeters to centimeters. Mitral valve abnormalities are common and impact repair techniques.
How can I be evaluated for the septal myectomy procedure?
To determine if myectomy is the right treatment option, you’ll need to be evaluated by a Cleveland Clinic cardiologist. If you are currently being treated by a doctor outside of Cleveland Clinic, chat online with a nurse , or please call the Heart Center Resource and Information Nurse toll-free at 866.289.6911 or 216.445.9288 for more information about getting an evaluation at Cleveland Clinic.
If you are already being seen at Cleveland Clinic for treatment of your heart condition, ask your cardiologist if myectomy surgery might be an appropriate treatment option for you.
Will my symptoms improve after surgery?
Yes. Surgical results indicate that most patients experience significant symptom improvement and an improved quality of life after surgery.
Full recovery from septal myectomy surgery takes about 6 to 8 weeks. Most patients are able to drive in about 3 to 8 weeks after surgery. Your doctor will provide specific guidelines for your recovery and return to work.
Follow Up Care
Your doctor will tell you when you need to have your first follow-up appointment. Regular follow-up appointments are important to evaluate your heart function and include a medical exam as well as diagnostic tests (such as an echocardiogram) to be repeated at regular intervals. During these appointments, your medications may be adjusted to relieve symptoms or optimize your heart function.
Even if you are not having symptoms and you feel fine, you must still see your doctor regularly. The frequency of your follow-up visits is based on your current health. In general, you will need to see your cardiologist for follow-up visits at least twice a year.
You should call your doctor if your symptoms become more severe or frequent. Don’t wait until your next appointment to discuss changes in your symptoms.
Importance of Making Lifestyle Changes
To maintain your health after surgery, it is important to take medications as prescribed and make lifestyle changes as recommended by your doctor to reduce the risk of disease progression or future disease. Lifestyle changes include:
- Eat a heart-healthy diet that includes following a 2,000 mg sodium (salt) diet
- Restrict fluids to 8 cups or less per day
- Quit smoking and using tobacco
- Treat high cholesterol
- Manage high blood pressure and diabetes
- Exercise regularly
- Maintain a healthy weight
- Weigh yourself every day and monitor for sudden weight gain of more than 2 pounds in a day or 5 pounds in a week; call your doctor if this occurs
- Control stress and anger
- Participate in a cardiac rehabilitation program, as recommended
- Follow up with your doctor regularly, as scheduled
What tests are needed before the surgery?
- A detailed echocardiogram (echo) provides information about heart function and septal wall thickness. Specialized echo tests may include exercise or the use of special drugs and may be needed to define the severity of obstruction and to assess the mitral valve
- If you do not have an implantable defibrillator or pacemaker, an MRI may also be obtained to evaluate the mitral valve structure and function.
- A diagnostic cardiac catheterization should be performed. If you have had this test within one year, you will be instructed to send the results to Cleveland Clinic for review.
- Routine blood tests, a chest X-ray and an electrocardiogram will also be performed.
Some of these tests and procedures may be done by your local cardiologist or at the Cleveland Clinic. Your Cleveland Clinic cardiologist will talk to you about these and other tests that maybe needed.
What can I expect before the surgery?
Before your surgery date, you will have a pre-surgical appointment where you will receive specific instructions about when and where to report for surgery, what to expect before and after surgery, and whether additional tests are needed. If you need to see another health care provider or need testing during this preoperative appointment, you may be at Cleveland Clinic all day or you may need to return another day.
During this appointment, you will have the opportunity to talk with a nurse or patient educator about the procedure. You may also meet with your surgeon and anesthesiologist.If you are already in the hospital and surgery is recommended, your health care team will give you information about pre-surgical tests and how to prepare for surgery.
What happens during surgery?
Anesthesia: General anesthesia is administered by a cardiothoracic anesthesiologist before surgery. The anesthesiology team uses state-of-the-art equipment and monitors to ensure you are safely anesthetized during the procedure.
Type of incision: A 6- to 8-inch incision is made down the center of the chest, dividing the sternum (breastbone) to provide the surgeon direct access to the heart.The thickened muscle is approached through the aortic valve so that no direct incisions into the heart muscle are required. The cut muscle heals on its own without needing to be sutured.
Heart-lung machine: The heart-lung machine, or cardiopulmonary bypass, is used during the procedure and takes over the heart’s normal functions so the surgeon can perform the procedure on a “still” heart.
Blood is routed through the heart-lung machine, and oxygen and carbon dioxide are exchanged in the blood by the machine and then pumped back into the body. By doing the work of the heart, the heart-lung machine helps protect your other organs while your heart is stopped. After the procedure is complete, the heart-lung machine is turned off, the heart starts beating on its own, and the flow of blood returns to normal.
Pacing wires: Temporary pacing wires and a chest tube to drain fluid are placed before the sternum is closed with special sternal wires. Then the skin and subcutaneous tissue is closed with internal, absorbable sutures. Sometimes a temporary pacemaker is attached to the pacing wires to regulate the heart rhythm until your condition improves.
How long does the procedure last?
The actual surgery lasts from 3 to 6 hours, however your family should expect additional time before and after surgery.
What should I expect after the surgery?
You will be transferred to an intensive care unit for close monitoring for about one to two days after the surgery. The monitoring during recovery includes continuous heart, blood pressure and oxygen monitoring and frequent checks of vital signs and other parameters, such as heart sounds.After you are transferred to the nursing unit, the hospital stay is about 3 to 5 more days. You will work with a cardiac rehabilitation specialist who will help you gradually increase your activity to aid your recovery. You can expect to stay in the hospital a total of 5 to 7 days, depending on your recovery.
Some patients may require an implantable cardioverter-defibrillator (ICD) to treat a serious abnormal heart rhythm. If this device is required, your cardiologist will discuss the details about the device and the implantation procedure.
Under certain circumstances, you may have a test called an EP study (electrophysiology study) before you go home to evaluate your heart rhythm.
Before you leave the hospital, you will receive specific information about incision care, medications, activity and diet guidelines, warning signs to look for and who to call after you go home.
Medications after surgery: You will continue to take your preoperative medications, as directed, until your follow-up appointment when your cardiologist may make adjustments to your medications.
Risks / Benefits
What are the possible risks of the surgery?
Your doctor will discuss the specific risks and potential benefits of the septal myectomy procedure with you. The procedure is generally very safe. However, as with any surgical procedure, there are risks related to your age, the presence of other medical conditions and the number of procedures you undergo during a single operation.Specific risks may include: infection; irregular heart rhythm, such as ventricular arrhythmia; chest pain or angina; heart attack, stroke or death. Special precautions are taken to reduce these very low risks.There may be other possible risks. When you meet with your doctor, please ask questions to make sure you understand why the procedure is recommended and all of the potential risks.Also, please discuss any concerns you may have about lying flat on your back for a prolonged period (3 to 6 hours) during the procedure.
How do I find a doctor if I have hypertrophic cardiomyopathy?
Cleveland Clinic's Hypertrophic Cardiomyopathy Center is a multidisciplinary specialty treatment group dedicated to the diagnosis and treatment of hypertrophic cardiomyopathy (HCM) in individuals and family members. We bring together clinicians that specialize in HCM, including physicians and nurses from Cardiovascular Medicine, Genetics, Cardiothoracic Surgery, Pediatric Cardiology, and Psychology. For pediatric care, please visit Cleveland Clinic's Center for Pediatric and Congenital Heart Diseases.
Where can I find more information?
If you have questions, you can chat online with a nurse or call the Miller Family Heart and Vascular Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.
The Hypertrophic Cardiomyopathy Association (HCMA) is dedicated to support and educate those with HCM, their families and other health care professionals. They may be contacted by phone at 973.983.7429 or email at [email protected]. You can also visit the HCMA website or reach them by mail at P.O. Box 306, Hibernia, NJ 07842.
Hypertrophic Cardiomyopathy: For Patients, Their Families and Interested Physicians: A very helpful guide for those with hypertrophic cardiomyopathy. Books can be ordered from the HCMA website.
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