Myectomy for Hypertrophic Obstructive Cardiomyopathy

What is Hypertrophic obstructive cardiomyopathy (HOCM)?
The heart is a pump made of specialized muscles. There are two sides of the heart – right and left. They are partitioned by a muscular wall that is known to have an interventricular septum. In the condition of Hypertrophic obstructive cardiomyopathy, the thickness of this septum is increased abnormally in a way that it obstructs the blood being pumped out of the left side of the heart . These obstructions due to abnormal thickness of the septum can occur at various levels and some of them can be treated with surgery.

Aim of surgery
Surgery is aimed at removing a slice of thickened muscular septum (Myectomy) to relieve obstruction of blood flowing out of the heart. Thereby it is likely to improve the symptoms of obstruction.

Other options for treatment of HOCM
Usually most patients with HOCM are treated with medications. Surgery is only advised if the symptoms persist despite medications or there are side effects of the medications. The other reasons to advise surgery involves development of other abnormalities in heart eg. leaking heart valve, irregular heart beat etc. If surgery cannot be considered then the second option is alcohol septal ablation which is administered by an interventional cardiologist with a catheter based approach. Alcohol septal ablation should be considered only if surgery is not an option.

What does the surgery involve?
Surgery is done under general anaesthesia. It can take anywhere between 3 to 4 hrs. Surgery is performed after splitting the breast bone with a midline incision on the chest. The heart is connected to the heart lung machine and stopped while the heart muscle is protected with a special solution.
Dr Joshi will open the big pipe (aorta) that is connected to the pumping chamber. He then cuts the slice of muscle from the left side of the thickened muscular septum while operating through the incision in the pipe. This operation is considered quite delicate as the surgeon can only see one side of the septum. Not infrequently, surgeons may need to repeat the procedure if more muscle needs to be sliced. If additional procedures are required then they are performed simultaneously eg. Ablation of atrial fibrillation, mitral valve surgery or aortic valve replacement etc. After finishing the surgery on the heart, it will be separated from the heart lung machine. Adequacy of the muscle excision (myectomy) will be checked by intraoperative echocardiogram prior to returning the patient to the ICU. ICU stay is generally 2 days and hospital stay is about 7 days.

What happens in the ICU?
Typically most patients are kept asleep with medications for 3-6 hrs to observe for stability. While you are asleep you will be breathing with the help of a breathing machine (ventilator). The ICU specialist (Intensivist) is in charge of your care while you recover in the ICU. When you wake up, It is normal to feel sleepy and weak. You will notice a few catheters, tubes and wires connected to your body which are routine. You will feel a bit uncomfortable with all those attached to your body. These attachments are removed as you progress in your care and most are removed by day 5. You will be helped to get out of bed and sit in a chair for a few hours to help your lungs breathe better. A physiotherapist will take you for a short walk on day 2 in the ICU. The stay in ICU is typically for 2 days. You will then be transferred to the cardiac ward for further care.

Pain is very subjective but overall it is uncommon for patients to experience severe pain. You will be given strong painkillers, some of which may have unpleasant side effects like nausea, vomiting and constipation. Nursing staff will manage your pain medication in close collaboration with you. You are encouraged to notify staff if your pain is unbearable, prevents you from deep breathing or keeps you awake.

Progress in ward
You will be in a room once you arrive in the ward. You will be connected to a monitor so nurses can see any alarming signals from your heart rhythm. You need to be careful that the monitor leads remain attached to your body properly. If they get detached, you should inform your nurse by pressing the call button. The most important thing in the ward is to start getting more mobile. You will be asked to walk 5 times every day and your physio will teach you exercises. Dr Joshi will give instructions for the removal of pacing wires. Removal of wires and lines are very tolerable. By day 5-7, you will be asked by physiotherapists to complete two flights of stairs. This is done to assess your fitness to be discharged home and your independent mobility. You will have regular blood tests, an echocardiogram and chest x rays. Electrolytes are frequently replaced with intravenous infusions.

Going home
Most patients are expected to be discharged between 7-10 days after surgery. The stay after this type of surgery is usually longer compared to other heart surgeries. You will receive discharge education from your nurse who will give you information about incisions, dressing, showering etc. A pharmacist will visit you to discuss your medications which might have changed a little bit. You must remember to take your discharge file with you,which should include all your instructions regarding follow up appointments, a medication list and other material. You should carry this file with you when you visit your cardiologist or cardiac surgeon for follow-up at 4-6 weeks.

Dressings
You will have a long dressing on your chest. You should remove it after 4 weeks under a running shower. You can remove it earlier if it starts to come off or breaks. If you have any concerns about the wound please visit your GP or notify Dr Joshi.

Follow up
You should arrange an appointment to see Dr Joshi in 6-8 weeks and your cardiologist in 8 weeks. You should visit your GP within a week after being discharged from hospital.

Risks of the surgery can vary quite a bit and vary according to patients. Each heart surgery has standard risks and specific complications associated with the type of procedure. The most important general complications to keep in mind are risk of stroke, infection, heart attack, bleeding and kidney injury. Post operative bleeding can occur after any heart operation due to disturbance in the blood clotting mechanisms after surgery. 30% of patients may develop irregular heart beats (atrial fibrillation) which is usually temporary and treated with medications. The specific risks are discussed at the time of consultation which also includes infection and kidney failure.

Specific complications that are particular for myectomy are the risk of permanent pacemaker (PPM) or left bundle branch block (ECG abnormality due to damage to electrical fibres in heart muscle during myectomy). The need for PPM is decided 4-5 days after your surgery allowing time for your electrical system to recover. If your electrical system does not recover within a week then Dr Joshi will ask the cardiologist to insert a PPM under local anaesthetic prior to your discharge from hospital. Insertion of PPM does not hold you long in hospital or affect your recovery adversely.

Another rare but life threatening complication of myectomy is inadvertent creation of a hole in the muscular septum which is a result of excessive myectomy. The complication is recognizable during surgery most of the time. The treatment for this complication is a patch repair of the hole.

Younger patients are a risk of developing fluid build up around the heart. This typically manifests at about 4 weeks. This is reactive fluid and younger patients are more prone. It is not harmful but can make some patients feel short of breath or feverish. If that happens you should present to ED or notify your cardiologist or Dr Joshi. The treatment involves anti-inflammatory medications and in some cases taking the fluid out with a needle or small incision.

If the risks of surgery are elevated then you will be informed about it at the time of consultation.

As such no blood thinners are prescribed with myectomy operation. However, if you have had other surgeries along with myectomy that included heart valve surgery or rhythm surgery then you may be placed on blood thinners.

Duration and type of blood thinner depends on the type of valve that is implanted in the heart. If you have a tissue valve implantation then you will be on warfarin for 3 months and if you have a mechanical/metal valve then you will be on warfarin for life . When your surgery is elective, this would be discussed with you prior to surgery.

If you are fitted with a tissue valve then Dr Joshi or your cardiologist will advise when you are able to stop warfarin. Generally, warfarin is replaced with Aspirin 100 mg daily after 3 months.

If you have had a valve repair then your warfarin will be stopped after 6-8 weeks and replaced with Aspirin 100 mg daily.

Dr Joshi will see you for follow up after 6 weeks and then your long term follow up is organised by your cardiologist and GP. Echocardiogram is done once or twice a year to monitor the function of your heart and is done as seen necessary by your cardiologist. If you are on warfarin then your GP will guide you regarding frequency of blood tests and dosage of warfarin.

One of the aims of myectomy surgery is to return to your normal life. If you have any limitations due to your heart issues then you should also get better, effectively improving the quality of your life. One would be expected to return completely back to normal life. However, if you are on warfarin or other blood thinners then necessary changes to your lifestyle are recommended.

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