What Is Septal Myectomy Surgery?

Septal myectomy is a surgical procedure primarily used to treat hypertrophic cardiomyopathy (HCM), a genetic condition characterised by the thickening of the heart muscle, specifically the septum, the wall separating the left and right sides of the heart. This thickening can obstruct the flow of blood from the heart, particularly from the left ventricle into the aorta, causing a condition known as left ventricular outflow tract obstruction (LVOTO).

Septal myectomy involves the removal of part of the thickened septal wall to improve blood flow and reduce the symptoms associated with HCM, such as shortness of breath, chest pain, and fainting.In this article, we will provide a detailed explanation of septal myectomy surgery, the conditions that lead to its necessity, the procedure itself, recovery, risks, and long-term outcomes.

We will also look at the current advancements in treatment for HCM and how septal myectomy compares to other treatment options.

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When Is Septal Myectomy Needed?

Septal myectomy is generally recommended when a patient with hypertrophic cardiomyopathy has significant symptoms or complications that are not responsive to medication or other non-invasive treatments.

The main goal of the surgery is to improve blood flow by removing a portion of the thickened septal tissue that obstructs the left ventricular outflow tract (LVOT), the area through which blood flows from the left ventricle into the aorta.

The procedure is usually considered for individuals who:

• Have symptoms that are not controlled with medication: Despite the use of medications like beta-blockers, calcium channel blockers, or disopyramide, many patients still experience symptoms that affect their daily lives.
• Have significant outflow obstruction: If the thickening of the septum causes a severe obstruction to blood flow, septal myectomy can help alleviate these problems.
• Are at high risk of sudden cardiac death: In some cases, septal myectomy may be recommended for patients with life-threatening arrhythmias that cannot be managed with medication or implantable devices such as pacemakers or defibrillators.
• Have other complications: For individuals who also experience mitral valve issues or other heart-related conditions that exacerbate their symptoms, septal myectomy can address the root cause of the obstruction.

How Is Septal Myectomy Performed?

Septal myectomy is a major open-heart surgery that typically requires general anaesthesia and a stay in a hospital for recovery. The surgery aims to remove a portion of the septal muscle to widen the left ventricular outflow tract, improving the flow of blood. Below is a step-by-step overview of how the procedure is typically performed:

Preparation:

The patient is first given general anaesthesia to ensure they are asleep and pain-free during the procedure. A breathing tube will be inserted, and the patient will be connected to a heart-lung machine that takes over the functions of the heart and lungs during surgery.

Incision:

The surgeon will make an incision down the middle of the chest (sternotomy) to access the heart. The sternum is then carefully divided to allow the surgeon to reach the heart. In some cases, a minimally invasive approach may be used, involving smaller incisions and robotic assistance, though this is less common.

Heart Exposure:

Once the chest is opened, the surgeon may use a variety of techniques to safely expose the heart. The heart-lung machine will be used to temporarily take over the function of pumping blood and oxygen to the body during this time.

Removing The Septal Tissue:

The surgeon will locate the thickened part of the septal wall and carefully remove a portion of it. The amount of tissue removed will depend on the degree of obstruction and the specific anatomy of the heart.

Mitral Valve Modification (If Necessary):

In some cases, the surgeon may also address issues with the mitral valve, which may become distorted due to the thickened septum, contributing to blood flow problems.

Closing The Incision:

After the necessary tissue has been removed, the surgeon will carefully check the blood flow to ensure the obstruction has been adequately addressed. The heart is restarted, and the chest is closed, with the sternum wired back together.

Recovery:

The patient will be moved to the intensive care unit (ICU) for monitoring. Recovery typically takes several days in the hospital, with full recovery taking several weeks to months.

Risks And Complications

As with any major surgery, septal myectomy carries risks, though these are generally low when performed by experienced surgeons in specialised centres. Some potential risks and complications include:

• Infection: Infection of the surgical site or the heart itself (endocarditis) is a potential risk.
• Bleeding: The surgery involves cutting into the heart tissue, and there is a risk of bleeding during or after the operation.
• Arrhythmias: The surgery may provoke arrhythmias, and in some cases, additional procedures may be needed to manage these irregular heartbeats.
• Heart failure: If the heart is unable to properly pump after the procedure, there may be a risk of heart failure.
• Stroke: As with any open-heart surgery, there is a small risk of stroke due to blood clots that may form during or after the procedure.
• Death: Although rare, there is a risk of death due to complications from the surgery or underlying heart conditions.

Recovery And Rehabilitation

After the surgery, patients are closely monitored in the hospital for several days. The recovery process typically involves:

Initial Recovery:

Patients will spend a few days in the ICU, where their vital signs, heart function, and recovery progress are carefully monitored. They may have a breathing tube temporarily.

Pain Management:

Pain control is an important part of recovery. The patient may be given pain medications to ensure they are comfortable during the recovery period.

Gradual Mobilisation:

Once stable, patients will be encouraged to sit up and move around slowly to help with circulation and prevent blood clots.

Physical Rehabilitation:

After discharge, physical therapy or rehabilitation may be recommended to help the patient regain strength and improve their cardiovascular fitness.

Follow-Up:

Regular follow-up appointments with the cardiologist are necessary to monitor the patient’s heart function and ensure that there are no complications. This will include echocardiograms, ECGs, and possibly a stress test.

Long-Term Outcomes

Septal myectomy has a high success rate, with many patients experiencing significant improvement in symptoms and quality of life. Studies have shown that after septal myectomy:

• Patients often experience a reduction in symptoms like shortness of breath, chest pain, and fatigue.
• The risk of sudden cardiac death is significantly reduced.
• There is improved exercise capacity and overall heart function.

However, the long-term success of septal myectomy depends on the severity of the patient’s condition and their response to the surgery. Some individuals may require ongoing medication or additional procedures to manage other aspects of their heart disease.

Alternatives To Septal Myectomy

While septal myectomy is a proven treatment for many people with hypertrophic cardiomyopathy, it is not the only option. Other treatments include:

• Medications: Beta-blockers and calcium channel blockers are often used to reduce symptoms by slowing the heart rate and decreasing the workload on the heart.
• Alcohol Septal Ablation (ASA): This is a less invasive procedure that involves injecting alcohol into the artery supplying the septum, which causes controlled damage to the tissue, reducing its thickness.
• Implantable Devices: For patients with arrhythmias or at risk of sudden cardiac arrest, an implantable cardioverter-defibrillator (ICD) may be recommended.

Conclusion

Septal myectomy is a highly effective surgical option for patients with hypertrophic cardiomyopathy who experience severe symptoms or complications that cannot be managed with medications alone. By removing a portion of the thickened septal tissue, septal myectomy helps to alleviate obstruction in the left ventricular outflow tract, thereby improving blood flow and the overall functioning of the heart.

Although it is a major surgery with associated risks, it has shown excellent long-term outcomes for many patients, leading to a significant improvement in their quality of life and a reduction in the risk of sudden cardiac death. For those with more advanced or complex HCM, septal myectomy may offer the best chance for long-term relief from symptoms and improved heart health.

Frequently Ask Question

Why Is Septal Myectomy Needed?

Septal myectomy is needed for patients with hypertrophic cardiomyopathy (HCM) whose condition does not respond to medication or other less invasive treatments. HCM causes the thickening of the heart’s septal muscle, which can obstruct blood flow and lead to symptoms such as difficulty breathing, chest pain, and even sudden cardiac arrest.

For patients experiencing severe symptoms or complications, septal myectomy offers a way to relieve these issues by removing the thickened tissue that blocks blood flow, thus improving heart function and quality of life.

How Is Septal Myectomy Performed?

Septal myectomy is performed under general anaesthesia, and it typically requires open-heart surgery. The surgeon makes an incision in the chest to access the heart. Once the heart is exposed, the surgeon removes a portion of the thickened septal muscle.

The procedure is usually performed through a sternotomy (cutting through the breastbone), though some minimally invasive techniques may be used in certain cases. After the thickened tissue is removed, the heart’s ability to pump blood is improved, and the patient’s symptoms are alleviated.

What Are The Benefits Of Septal Myectomy? 

Hypertrophic cardiomyopathy (HCM), such as shortness of breath, chest pain, and fatigue. The procedure can also reduce the risk of sudden cardiac arrest, a dangerous complication associated with HCM. Most patients experience a better quality of life after the surgery, with improved exercise tolerance and fewer restrictions in daily activities.

Septal myectomy has a high success rate, especially in experienced centres, and can provide long-term relief from HCM symptoms.