Difference between revisions of "Septal myectomy/myotomy"

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{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}


Provide a brief summary here.
== Overview ==
Myotomy and septal myectomy are surgical procedures used primarily to treat hypertrophic obstructive cardiomyopathy (HOCM). This condition is characterized by the thickening of the heart muscle, particularly the interventricular septum, which can obstruct blood flow.
=== Indications<!-- List and/or describe the indications for this surgical procedure. --> ===
* Hypertrophic obstructive cardiomyopathy (HOCM)
** Symptoms: dyspnea, palpitations, arrhythmia, syncope, heart failure, stroke, and sudden death
** Management of this condition can be medical, electrophysiological or surgical.  This article will focus primarily on the open surgical technique<ref name=":0">{{Cite journal|last=Wigle|first=E. Douglas|last2=Rakowski|first2=Harry|last3=Kimball|first3=Brian P.|last4=Williams|first4=William G.|date=1995-10|title=Hypertrophic Cardiomyopathy|url=https://www.ahajournals.org/doi/full/10.1161/01.CIR.92.7.1680|journal=Circulation|volume=92|issue=7|pages=1680–1692|doi=10.1161/01.CIR.92.7.1680}}</ref>
* Symptomatic left ventricular outflow tract (LVOT) obstruction
* Severe mitral regurgitation due to systolic anterior motion (SAM) of the mitral valve
* Refractory symptoms despite medical management (e.g., dyspnea, syncope)
=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===
* TEE (transesophageal echocardiography) used intraoperatively to guide resection and assess results.
== Preoperative management ==
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Direct vs. indirect laryngoscopy
|-
|Neurologic
|Paralysis, CPB
|-
|Cardiovascular
|Biventricular function, valvular abnormalities,  integrity of conduction and presence of arrhythmias
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|Coagulopathy, may be exacerbated by CPB
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
* '''Cardiology Assessment''': Detailed history and physical examination.
* '''Imaging''': Echocardiogram to assess septal thickness and LVOT gradient. Cardiac MRI may also be used.
* '''Functional Testing''': Stress testing to evaluate symptomatology and obstruction severity.
* Labs
** CBC
** CMP
** Coagulation studies
** Blood cultures
** +/- TEG if patient has history of comorbid condition that affects coagulopathy
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
* Continued use of beta-blockers or calcium channel blockers until surgery.
* Consider anxiolytics like midazolam.
== Intraoperative management ==
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
* Standard ASA monitors
* Arterial line
* Central access CVP +/- PA pressures(indicated for RV or LV failure)
* Transesophageal echo(TEE)
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
* General anesthesia with endotracheal intubation.
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
* Supine position for surgical access.
* Shoulder roll
* Arms tucked
=== Maintenance and surgical considerations ===
* LV systolic function in patients with HOCM are usually normal to supranormal with a high ejection fraction.<ref name=":1">{{Cite journal|last=Cregg|first=Nuala|last2=Cheng|first2=Davy C. H.|last3=Karski|first3=Jacek M.|last4=Williams|first4=William G.|last5=Webb|first5=Gary|last6=Wigle|first6=E. Douglas|date=1999-02-01|title=Morbidity outcome in patients with hypertrophic obstructive cardiomyopathy undergoing cardiac septal myectomy: Early-extubation anesthesia versus high-dose opioid anesthesia technique|url=https://www.sciencedirect.com/science/article/pii/S1053077099901738|journal=Journal of Cardiothoracic and Vascular Anesthesia|volume=13|issue=1|pages=47–52|doi=10.1016/S1053-0770(99)90173-8|issn=1053-0770}}</ref>
* Diastolic dysfunction in patients with HOCM is caused by decreased ventricular compliance and impaired ventricular relaxation.<ref name=":0" />
* Promote:
** Increased preload
*** Trendelenburg positioning may be used for episodes of hypotension
** Adequate afterload
* Avoid:
** Vasodilators
** Decreases in SVR
** Increased inotropy
** Increased chronotropy
*** Can be treated in perioperative period with B-antagonists(ex. esmolol)<ref name=":1" />
** Outflow tract obstruction
<nowiki>*</nowiki>Interestingly, halothane has a good profile for patients with HOCM, given it decreases contractility and heart rate.
=== <!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
== Postoperative management ==
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
* Intensive care unit (ICU) monitoring initially.
** Often intubated
** Frequently requiring pressors or inotropic agents post-CPB.
* Continuous ECG monitoring for arrhythmias.
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
* Arrhythmias (atrial fibrillation, ventricular arrhythmias)
* Ventricular septal defect
* Mitral regurgitation
* Bleeding or pericardial effusion
* AV node block requiring pacemaker insertion
* CPB specific complications
**
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}
== References ==
[[Category:Surgical procedures]]

Revision as of 22:09, 24 June 2025

Septal myectomy/myotomy
Anesthesia type
Airway
Lines and access
Monitors
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
Article quality
Editor rating
Unrated
User likes
0

Provide a brief summary here.

Overview

Myotomy and septal myectomy are surgical procedures used primarily to treat hypertrophic obstructive cardiomyopathy (HOCM). This condition is characterized by the thickening of the heart muscle, particularly the interventricular septum, which can obstruct blood flow.

Indications

  • Hypertrophic obstructive cardiomyopathy (HOCM)
    • Symptoms: dyspnea, palpitations, arrhythmia, syncope, heart failure, stroke, and sudden death
    • Management of this condition can be medical, electrophysiological or surgical. This article will focus primarily on the open surgical technique[1]
  • Symptomatic left ventricular outflow tract (LVOT) obstruction
  • Severe mitral regurgitation due to systolic anterior motion (SAM) of the mitral valve
  • Refractory symptoms despite medical management (e.g., dyspnea, syncope)

Surgical procedure

  • TEE (transesophageal echocardiography) used intraoperatively to guide resection and assess results.

Preoperative management

Patient evaluation

System Considerations
Airway Direct vs. indirect laryngoscopy
Neurologic Paralysis, CPB
Cardiovascular Biventricular function, valvular abnormalities, integrity of conduction and presence of arrhythmias
Pulmonary
Gastrointestinal
Hematologic Coagulopathy, may be exacerbated by CPB
Renal
Endocrine
Other

Labs and studies

  • Cardiology Assessment: Detailed history and physical examination.
  • Imaging: Echocardiogram to assess septal thickness and LVOT gradient. Cardiac MRI may also be used.
  • Functional Testing: Stress testing to evaluate symptomatology and obstruction severity.
  • Labs
    • CBC
    • CMP
    • Coagulation studies
    • Blood cultures
    • +/- TEG if patient has history of comorbid condition that affects coagulopathy

Patient preparation and premedication

  • Continued use of beta-blockers or calcium channel blockers until surgery.
  • Consider anxiolytics like midazolam.

Intraoperative management

Monitoring and access

  • Standard ASA monitors
  • Arterial line
  • Central access CVP +/- PA pressures(indicated for RV or LV failure)
  • Transesophageal echo(TEE)

Induction and airway management

  • General anesthesia with endotracheal intubation.

Positioning

  • Supine position for surgical access.
  • Shoulder roll
  • Arms tucked

Maintenance and surgical considerations

  • LV systolic function in patients with HOCM are usually normal to supranormal with a high ejection fraction.[2]
  • Diastolic dysfunction in patients with HOCM is caused by decreased ventricular compliance and impaired ventricular relaxation.[1]
  • Promote:
    • Increased preload
      • Trendelenburg positioning may be used for episodes of hypotension
    • Adequate afterload
  • Avoid:
    • Vasodilators
    • Decreases in SVR
    • Increased inotropy
    • Increased chronotropy
      • Can be treated in perioperative period with B-antagonists(ex. esmolol)[2]
    • Outflow tract obstruction

*Interestingly, halothane has a good profile for patients with HOCM, given it decreases contractility and heart rate.

Emergence

Postoperative management

Disposition

  • Intensive care unit (ICU) monitoring initially.
    • Often intubated
    • Frequently requiring pressors or inotropic agents post-CPB.
  • Continuous ECG monitoring for arrhythmias.

Pain management

Potential complications

  • Arrhythmias (atrial fibrillation, ventricular arrhythmias)
  • Ventricular septal defect
  • Mitral regurgitation
  • Bleeding or pericardial effusion
  • AV node block requiring pacemaker insertion
  • CPB specific complications

Procedure variants

Variant 1 Variant 2
Unique considerations
Indications
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

  1. ↑ 1.0 1.1 Wigle, E. Douglas; Rakowski, Harry; Kimball, Brian P.; Williams, William G. (1995-10). "Hypertrophic Cardiomyopathy". Circulation. 92 (7): 1680–1692. doi:10.1161/01.CIR.92.7.1680. Check date values in: |date= (help)
  2. ↑ 2.0 2.1 Cregg, Nuala; Cheng, Davy C. H.; Karski, Jacek M.; Williams, William G.; Webb, Gary; Wigle, E. Douglas (1999-02-01). "Morbidity outcome in patients with hypertrophic obstructive cardiomyopathy undergoing cardiac septal myectomy: Early-extubation anesthesia versus high-dose opioid anesthesia technique". Journal of Cardiothoracic and Vascular Anesthesia. 13 (1): 47–52. doi:10.1016/S1053-0770(99)90173-8. ISSN 1053-0770.

Top contributors: Giovanni Perottino

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