Pearls and Pitfalls of Septal Myectomy

Pearls and Pitfalls of
Septal Myectomy
Nicholas Smedira, MD
Staff Surgeon, Heart & Vascular Institute
Cleveland Clinic
Cleveland, Ohio
Myectomy
Pearls and Pitfalls
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HCM Team
LVOTO anatomy and the countless
variations
Imaging expert
Surgical Pearls
Q15. The average number of myectomies you perform each year is:
a.
b.
c.
d.
<5
10‐20
20‐50
>50
Myectomy
>1600
180
120
#
60
0
95
97
99
01
03
05
Year
07
09
11
13
HCM Team
• 4 Dedicated Adult Cardiologist (1 Florida), 1
Pediatric Cardiologist
• EP ( ICD and atrial fibrillation)
• Imaging Specialists (MRI/Echo)
• Stress Testing
• Genetic Counseling
• Pathologist
• Infiltrative Cardiomyopathy Expert (amyloid,
glycogen storage diseases)
• Transplantation
Anatomy
HCM - Age Variations
YOUNG
OLD
Aortic Valve/LVOT Angles
Becker et al; Operative Techniques in Cardiac & Thoracic Surgery, 1996: 1 (17) p. 10
Aortic/Mitral Valve/LVOT
Angles
Becker et al; Operative Techniques in Cardiac & Thoracic Surgery, 1996: 1 (17) p. 10
Abnormal LV inflow to outflow angle
Normal
Hypertrophic cardiomyopathy
Abnormal LVOT to aortic angle in 153 patient HCM study
Independent predictor of LVOT gradient
Ventriculo-vascular coupling, a missing connection ?
Kwon D, Desai MY. Heart 2009
Surgical Procedure
Q16. Do you have a echocardiographer ( echo certified anesthesiologist or cardiology imaging specialist) present for myectomies
or valve repairs?
a. Yes
b. No
TEE in HCM: Long Axis or 120-135°
TEE in HCM: 4 Chamber View
Q17. The best way to assess residual outflow tract obstruction after a myectomy is to provoke with:
a.
b.
c.
d.
Pacing
Isuprel
Vasodilation with nitroglycerin
all of the above
Post Myectomy Provocation
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Patience
Fully deair the heart
Normal RV function
Isuprel at 20 ug/min
Pace at 110-120
Vasodilators for systolic pressure >100
Keep empty
Good transgastric image of aortic valve