Septal myectomy/myotomy - Revision history

Giovimixele at 19:30, 9 July 2025

2025-07-09T19:30:40Z

← Older revision		Revision as of 12:30, 9 July 2025
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	=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

			* Regional anesthetic techniques for sternotomy
			* Long acting opiates(dilaudid or methadone)
			* Tylenol
			* Avoid NSAIDs given patients undergoing cardiac surgery are at higher risk for kidney injury and patients are often coagulopathic from CPB

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

Giovimixele at 19:30, 9 July 2025

2025-07-09T19:30:18Z

← Older revision		Revision as of 12:30, 9 July 2025
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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_preoperative =~~
	\| 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 ~~sytolic~~ 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>		* 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
	\|~~Coagulopathy, may be exacerbated by~~ CPB		\|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 ==
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	* AV node block requiring pacemaker insertion		* AV node block requiring pacemaker insertion
	* CPB specific complications		* CPB specific complications
	**

	== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

	~~{\| class="wikitable wikitable-horizontal-scroll"~~
	\|+
	!
	~~!Variant 1~~
	~~!Variant 2~~
	\|-
	~~\|Unique considerations~~
	\|
	\|
	\|-
	~~\|Indications~~
	\|
	\|
	\|-
	~~\|Position~~
	\|
	\|
	\|-
	~~\|Surgical time~~
	\|
	\|
	\|-
	~~\|EBL~~
	\|
	\|
	\|-
	~~\|Postoperative disposition~~
	\|
	\|
	\|-
	~~\|Pain management~~
	\|
	\|
	\|-
	~~\|Potential complications~~
	\|
	\|
	\|}

	== References ==		== References ==

	[[Category:Surgical procedures]]		[[Category:Surgical procedures]]

Giovimixele at 17:28, 26 June 2025

2025-06-26T17:28:53Z

← Older revision		Revision as of 10:28, 26 June 2025
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	*#Right atrial cannulation		*#Right atrial cannulation
	*#Insertion of aortic root and the LV vent<ref>{{Cite web\|title=Surgical setup for cardiopulmonary bypass through central cannulation\|url=https://mmcts.org/tutorial/1663\|access-date=2025-06-25\|website=MMCTS\|language=en}}</ref>		*#Insertion of aortic root and the LV vent<ref>{{Cite web\|title=Surgical setup for cardiopulmonary bypass through central cannulation\|url=https://mmcts.org/tutorial/1663\|access-date=2025-06-25\|website=MMCTS\|language=en}}</ref>
			*#Resection of hypertrophic ventricular septum

	== Preoperative management ==		== Preoperative management ==

Giovimixele: Created article

2025-06-25T06:41:28Z

Created article

← Older revision		Revision as of 23:41, 24 June 2025
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	* Hypertrophic obstructive cardiomyopathy (HOCM)		* Hypertrophic obstructive cardiomyopathy (HOCM)
	** Symptoms: dyspnea, palpitations, arrhythmia, syncope, heart failure, stroke, and sudden death		**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<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		* Symptomatic left ventricular outflow tract (LVOT) obstruction with eventual development of LV sytolic 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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	* TEE (transesophageal echocardiography) used intraoperatively to guide resection and assess results.		* 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<ref>{{Cite web\|title=Surgical setup for cardiopulmonary bypass through central cannulation\|url=https://mmcts.org/tutorial/1663\|access-date=2025-06-25\|website=MMCTS\|language=en}}</ref>

	== Preoperative management ==		== Preoperative management ==
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	* General anesthesia with endotracheal intubation.		* 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<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===		=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
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	<nowiki>*</nowiki>Interestingly, halothane has a good profile for patients with HOCM, given it decreases contractility and heart rate.		<nowiki>*</nowiki>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 <ref name=":2" />
			** Avoid medications with B-agonist activity as they worsen LVOT obstruction due to positive chronotropy and inotropy caused by B-adrenergic agents. <ref>{{Cite journal\|last=Varma\|first=Praveen Kerala\|last2=Raman\|first2=Suneel Puthuvassery\|last3=Neema\|first3=Praveen Kumar\|date=2014\|title=Hypertrophic cardiomyopathy part II--anesthetic and surgical considerations\|url=https://pubmed.ncbi.nlm.nih.gov/24994732\|journal=Annals of Cardiac Anaesthesia\|volume=17\|issue=3\|pages=211–221\|doi=10.4103/0971-9784.135852\|issn=0974-5181\|pmid=24994732}}</ref>
			** Maintain NSR, as the noncompliant LV increasingly relies on atrial kick for adequate end-diastolic volume<ref name=":1" />

	=== <!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== <!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
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	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
			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.<ref name=":3">{{Cite journal\|last=Pruna-Guillen\|first=Robert\|last2=Pereda\|first2=Daniel\|last3=Castellà\|first3=Manuel\|last4=Sandoval\|first4=Elena\|last5=Affronti\|first5=Alessandro\|last6=García-Álvarez\|first6=Ana\|last7=Perdomo\|first7=Juan\|last8=Ibáñez\|first8=Cristina\|last9=Jordà\|first9=Paloma\|last10=Prat-González\|first10=Susanna\|last11=Alcocer\|first11=Jorge\|date=2021-08-08\|title=Outcomes of Septal Myectomy beyond 65 Years, with and without Concomitant Procedures\|url=https://pmc.ncbi.nlm.nih.gov/articles/PMC8397149/\|journal=Journal of Clinical Medicine\|volume=10\|issue=16\|pages=3499\|doi=10.3390/jcm10163499\|issn=2077-0383\|pmc=8397149\|pmid=34441795}}</ref>. In this study there was a median post op ICU stay of <24 hours<ref name=":3" />, while the national average is > 48 hours. One other study paints a less ''rosy'' picture but study a more elderly population.<ref>{{Cite journal\|last=Jahnlová\|first=Denisa\|last2=Tomašov\|first2=Pavol\|last3=Adlová\|first3=Radka\|last4=Januška\|first4=Jaroslav\|last5=Krejčí\|first5=Jan\|last6=Dabrowski\|first6=Maciej\|last7=Veselka\|first7=Josef\|date=2019-05\|title=Outcome of patients ≥ 60 years of age after alcohol septal ablation for hypertrophic obstructive cardiomyopathy\|url=https://pubmed.ncbi.nlm.nih.gov/31110530\|journal=Archives of medical science: AMS\|volume=15\|issue=3\|pages=650–655\|doi=10.5114/aoms.2019.84735\|issn=1734-1922\|pmc=6524201\|pmid=31110530}}</ref> 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)		* Arrhythmias (atrial fibrillation, ventricular arrhythmias)
	* Ventricular septal defect		* Ventricular septal defect

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