myectomy

Surgery - the myectomy of the interventricular septum - is considered by the European and American guidelines as the best cure (the so-called "gold standard") for the treatment of obstructive hypertrophic cardiomyopathy in patients who remain symptomatic despite maximum drug therapy.

What are the benefits of myectomy?

From studies conducted at our Centre and from international multicenter studies, myectomy in subjects with obstructive hypertrophic cardiomyopathy has proven very effective in improving symptoms such as breathlessness (dyspnea), chest pain (angina), pre-lipotimias and syncopes. These symptoms are reduced and disappear completely in the majority of patients. It has also been shown to provide a significant improvement in survival compared to patients who do not undergo the surgery. In symptomatic subjects who underwent myectomy, survival was comparable to the general population compared by sex and age.

What is myectomy?

Myectomy is a cardiac surgery aimed at removing the portion of the heart muscle (myocardium) that causes the obstruction of blood flow from the left ventricle to the aorta (the main artery that carries blood to the whole body). The operation consists in removing the excess portion of myocardium by means of calibrated cuts in order to normalize the size of the interventricular septum. The cardiac surgeon expert in this pathology, inspecting the interventricular septum after a careful analysis of the echocardiogram and the Cardiac Magnetic Resonance imaging, removes the excess portion completely eliminating the obstruction and the associated structural abnormalities.

What are the risks of myectomy?

Myectomy is a cardiac surgery and therefore involves general anesthesia, sternotomy and extracorporeal circulation. Like any surgery, it is not without risks, which are also linked to age and the presence of comorbidities. The doctor will discuss the various risks in the specific case. It is recommended to perform this intervention in dedicated referral centers o and with decades of experience; at our Centre the intervention is performed systematically since 1996 and more than 250 patients have been operated with excellent results.

How long does the operation last and after how many days can I go home?

The operation lasts about 4 hours from the entrance to the operating room, but the times vary greatly from case to case. The stay in intensive care, where the various vital parameters are monitored very accurately, is about 12-24 hours, while the stay in the ward is about 7 days. Subsequently, depending on the age of the patient and the pre-operative conditions, we recommend a further period of about 1-2 weeks of rehabilitation in a facility connected to our hospital.

When will I be able to get back to life as before?

A full recovery after a myectomy occurs after about 6-8 weeks. Most patients return to driving after 4-8 weeks. The return to work depends on the type of work and functional recovery.

What examinations do I have to do before performing a myectomy?

At our Centre all patients with hypertrophic cardiomyopathy are followed by a Team of experts in this disease, which consists of Cardiologists, Cardiac surgeons, Electrophysiologists (cardiologists specializing in conduction disorders and cardiac arrhythmias), Anaesthetists and Geneticists. Before surgery, a careful clinical history is collected, including family history, and are perfomed: an accurate physical examination, an electrocardiogram to identify any cardiac blockages, a transthoracic echocardiogram to quantify the degree of obstruction and locate its location, to assess the extent of heart thickening and associated diseases of the mitral valve. Subsequently, patients undergo a Cardiac Magnetic Resonance imaging (CMR) that precisely helps to delineate the site of the obstruction. In addition, coronary angiogram is almost always performed to see if there are any coronary arteries disease. In special cases, an exercise echocardiogram is also performed to better quantify the degree of obstruction. In our centre it is also possible to perform a genetic test of the latest generation to identify a possible genetic mutation.

Should the mitral valve be replaced?

The mitral valve, a valve between the upper (atrium) and lower (ventricle) chambers of the left heart, has the function of preventing blood from flowing back when the ventricle contracts. This valve is frequently altered in patients with obstructive hypertrophic cardiomyopathy and there is often mitral insufficiency (blood returns back to the atria when the heart contracts); however, this insufficiency is often caused by the outflow tract obstruction and with myectomy, which removes this obstruction, it is also possible to reduce, until it is completely eliminated, the mitral insufficiency without the need to replace the valve. Surgical techniques have been developed at our Centre which, even in special cases, make it possible to avoid replacing the mitral valve with an artificial prosthesis.

Is it true that after myectomy I have to implant a pacemaker?

Very rarely, patients who have undergone myectomy have to implant a pacemaker. Often, these patients already have alterations in the conduction of the heart impulse before surgery. The assessment of the need to implant a pacemaker after a myectomy is, however, made by a Team of Cardiologists, Electrophysiologists (cardiologists specializing in conduction disorders and cardiac arrhythmias) and Cardiac surgeons experienced in this disease, after careful examination of continuous electrocardiogram monitoring and, sometimes, an electrophysiological study.

Is the surgical scar very large?

The surgical scar is the same for all the other cardiac surgery in young subjects can be reduced in size and called mini sternotomy.

Can myectomy also be performed in children?

Some pediatric patients with hypertrophic obstructive cardiomyopathy require myectomy surgery and can be operated on. Even patients with 1 year of age have been operated on at our Centre.

Are there alternatives to surgery?

There are two alternative therapies to myectomy surgery.

One is the implantation of a pacemaker, but this technique has proved ineffective and is rarely recommended.

Alcohol septal ablation a possible alternative to surgery. The operation consists of causing a programmed heart attack by injecting alcohol into the coronary arteries that carry the blood into the thickened portion of the heart. Since it is not possible to precisely locate the site of the "programmed" heart attack, sometimes the procedure is ineffective, and is also associated with a higher percentage of pacemaker implantation. For this reason, at our Centre this procedure is recommended only in patients with major contraindications to perform a surgical operation.