Difference between revisions of "Septal myectomy/myotomy"
From WikiAnesthesia
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{{Infobox surgical procedure | {{Infobox surgical procedure | ||
| anesthesia_type = | | anesthesia_type = General endotracheal anesthesia | ||
| airway = | | airway = ETT | ||
| lines_access = | | lines_access = 2+ PIVs, central venous access +/- Swan, arterial line | ||
| monitors = | | monitors = Standard, arterial line, PA catheter, TEE | ||
| considerations_intraoperative = | | considerations_intraoperative = | ||
| considerations_postoperative = | | considerations_postoperative = Disposition to ICU while sedated. Disposition with inotropy as patient is weaned from bypass | ||
}} | }} | ||
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**Symptoms: dyspnea, palpitations, arrhythmia, syncope, heart failure, stroke, and sudden death | **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> | ** 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 with eventual development of LV | * Symptomatic left ventricular outflow tract (LVOT) obstruction with eventual development of LV systolic failure symptoms<ref name=":2">{{Cite journal|last=Bellas|first=José J. Arcas|last2=Sánchez|first2=Cristina|last3=González|first3=Ana|last4=Forteza|first4=Alberto|last5=López|first5=Verónica|last6=Fernández|first6=Javier García|date=2021|title=Hypertrophic cardiomyopathy surgery: Perioperative anesthetic management with two different and combined techniques|url=https://pmc.ncbi.nlm.nih.gov/articles/PMC8191267/|journal=Saudi Journal of Anaesthesia|volume=15|issue=2|pages=189–192|doi=10.4103/sja.sja_952_20|issn=1658-354X|pmc=8191267|pmid=34188639}}</ref> | ||
* Severe mitral regurgitation due to systolic anterior motion (SAM) of the mitral valve | * Severe mitral regurgitation due to systolic anterior motion (SAM) of the mitral valve | ||
* Refractory symptoms despite medical management (e.g., dyspnea, syncope) | * Refractory symptoms despite medical management (e.g., dyspnea, syncope) | ||
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|- | |- | ||
|Pulmonary | |Pulmonary | ||
| | |Orthopnea, dyspnea on exertion. Assess ability to wean from ventilator and secure airway postoperatively | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
| | |Rule out esophageal abnormalities, varices, issues swallowing given TEE | ||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | |Starting H/H for CPB management/sequestration/priming of CPB cannulas. Assess underlying coagulopathy or anticoagulation given need for CPB | ||
|- | |- | ||
|Renal | |Renal | ||
| | |Assess renal function(cardiac surgery holds increased risk of AKI) | ||
|- | |- | ||
|Endocrine | |Endocrine | ||
| | |Assess history of diabetes, preoperative A1C(CPB is associated with hyperglycemia. Hyperglycemia is associated with worsened outcomes) | ||
|- | |- | ||
|Other | |Other | ||
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=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
Transport to ICU while sedated, and often while intubated | |||
== Postoperative management == | == Postoperative management == | ||
| Line 156: | Line 156: | ||
* AV node block requiring pacemaker insertion | * AV node block requiring pacemaker insertion | ||
* CPB specific complications | * CPB specific complications | ||
== References == | == References == | ||
[[Category:Surgical procedures]] | [[Category:Surgical procedures]] | ||
Revision as of 11:30, 9 July 2025
Septal myectomy/myotomy
| Anesthesia type |
General endotracheal anesthesia |
|---|---|
| Airway |
ETT |
| Lines and access |
2+ PIVs, central venous access +/- Swan, arterial line |
| Monitors |
Standard, arterial line, PA catheter, TEE |
| Primary anesthetic considerations | |
| Preoperative |
{{{considerations_preoperative}}} |
| Intraoperative | |
| Postoperative |
Disposition to ICU while sedated. Disposition with inotropy as patient is weaned from bypass |
| Article quality | |
| Editor rating | |
| 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)
- Autosomal dominant disorder characterized by hypertrophy of the LV
- 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 with eventual development of LV systolic failure symptoms[2]
- 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.
- CPB as a topic is beyond the scope of this article but will be discussed briefly with the general steps below
- Median sternotomy
- Exposure of the heart
- Aortic cannulation
- Right atrial cannulation
- Insertion of aortic root and the LV vent[3]
- Resection of hypertrophic ventricular septum
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 | Orthopnea, dyspnea on exertion. Assess ability to wean from ventilator and secure airway postoperatively |
| Gastrointestinal | Rule out esophageal abnormalities, varices, issues swallowing given TEE |
| Hematologic | Starting H/H for CPB management/sequestration/priming of CPB cannulas. Assess underlying coagulopathy or anticoagulation given need for CPB |
| Renal | Assess renal function(cardiac surgery holds increased risk of AKI) |
| Endocrine | Assess history of diabetes, preoperative A1C(CPB is associated with hyperglycemia. Hyperglycemia is associated with worsened outcomes) |
| 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.
- Propofol or thiopental may be used, with careful consideration of dose given the myocardial depressant effects and decreased afterload they cause. Etomidate is also an option given its relative lack of effect on the cardiovascular system.
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.[4]
- 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
- Increased preload
- Avoid:
- Vasodilators
- Decreases in SVR
- Increased inotropy
- Increased chronotropy
- Can be treated in perioperative period with B-antagonists(ex. esmolol)[4]
- Outflow tract obstruction
*Interestingly, halothane has a good profile for patients with HOCM, given it decreases contractility and heart rate.
- Hypotension
- Should be treated with increased intravascular volume and increased afterload [2]
- Avoid medications with B-agonist activity as they worsen LVOT obstruction due to positive chronotropy and inotropy caused by B-adrenergic agents. [5]
- Maintain NSR, as the noncompliant LV increasingly relies on atrial kick for adequate end-diastolic volume[4]
Emergence
Transport to ICU while sedated, and often while intubated
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
While cardiac surgery is high risk in its nature, septal myectomy is relatively safe procedure with excellent outcomes in improving obstructive pathology and symptoms of sytolic heart failure. One retrospective study of 65 patients who underwent open SM found < 1.9% required pacemaker insertion of mechanical circulatory support.[6]. In this study there was a median post op ICU stay of <24 hours[6], while the national average is > 48 hours. One other study paints a less rosy picture but study a more elderly population.[7] They evaluated 156 patients who had undergone open SM and found < 2.9% mortality at post op day 30%, 11.9% of patients requiring permanent pacemaker insertion, 24% suffering from residual significant obstruction.
- Arrhythmias (atrial fibrillation, ventricular arrhythmias)
- Ventricular septal defect
- Mitral regurgitation
- Bleeding or pericardial effusion
- AV node block requiring pacemaker insertion
- CPB specific complications
References
- ↑ 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) - ↑ 2.0 2.1 Bellas, José J. Arcas; Sánchez, Cristina; González, Ana; Forteza, Alberto; López, Verónica; Fernández, Javier García (2021). "Hypertrophic cardiomyopathy surgery: Perioperative anesthetic management with two different and combined techniques". Saudi Journal of Anaesthesia. 15 (2): 189–192. doi:10.4103/sja.sja_952_20. ISSN 1658-354X. PMC 8191267 Check
|pmc=value (help). PMID 34188639. - ↑ "Surgical setup for cardiopulmonary bypass through central cannulation". MMCTS. Retrieved 2025-06-25.
- ↑ 4.0 4.1 4.2 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.
- ↑ Varma, Praveen Kerala; Raman, Suneel Puthuvassery; Neema, Praveen Kumar (2014). "Hypertrophic cardiomyopathy part II--anesthetic and surgical considerations". Annals of Cardiac Anaesthesia. 17 (3): 211–221. doi:10.4103/0971-9784.135852. ISSN 0974-5181. PMID 24994732.
- ↑ 6.0 6.1 Pruna-Guillen, Robert; Pereda, Daniel; Castellà, Manuel; Sandoval, Elena; Affronti, Alessandro; García-Álvarez, Ana; Perdomo, Juan; Ibáñez, Cristina; Jordà, Paloma; Prat-González, Susanna; Alcocer, Jorge (2021-08-08). "Outcomes of Septal Myectomy beyond 65 Years, with and without Concomitant Procedures". Journal of Clinical Medicine. 10 (16): 3499. doi:10.3390/jcm10163499. ISSN 2077-0383. PMC 8397149 Check
|pmc=value (help). PMID 34441795 Check|pmid=value (help). - ↑ Jahnlová, Denisa; Tomašov, Pavol; Adlová, Radka; Januška, Jaroslav; Krejčí, Jan; Dabrowski, Maciej; Veselka, Josef (2019-05). "Outcome of patients ≥ 60 years of age after alcohol septal ablation for hypertrophic obstructive cardiomyopathy". Archives of medical science: AMS. 15 (3): 650–655. doi:10.5114/aoms.2019.84735. ISSN 1734-1922. PMC 6524201. PMID 31110530. Check date values in:
|date=(help)