An eight-year-old boy with hypertrophic cardiomyopathy underwent an extended septal myectomy. This video shows the pre-operative echo, and describes each step of the surgical technique.
Note: This video was originally published with the title “Extended Septal Myomectomy.”
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8 Comments
Congratulations for the nice description of this technique of septal myectomy. The title and description should be corrected though: there is no “myoma” resection (e.g. “myomectomy”), but resection of septal muscle, that is myectomy. It’s very hard to see precisely were the surgeon is making the incisions with a handheld, above the surgeon camera as in this example. Either a headlamp-mounted or endoscope would provide better visualization.
Agree. Myectomy is the right terminology, I’m encountering the same problem at my Institution with cardiologists who insist to call this procedure myomectomy. Do you measure direct intracardiac intraopertive gradients? if yes, how? Have you consider approaching this patient’s LV septum transapically as well?
Agree with comments from above. This is an operation in the heart. The right term is myectomy. In your postop echo the LVOT appears to be wide open but I don’t see you performing provocative maneuvers to elucidate gradients (either mechanical or pharmacological provocation). TEE images are not scrutinizing the mid ventricular level appropiately after surgery (papillary muscle level) and this case remains at risk of mid ventricular obstruction with persistence of symptoms. More data is needed to judge whether an additional LV approach would have been useful.
Thank you for your comments
i agree with your comment that it should be Myectomy
Regarding intraoperative gradient measurement—- in last part of video we have shown how to measure LV cavity pressure with needle directly inserted from surface.it is 20 gauze long lenth needle, inserted though RV surface, IVS and LV.You can see wave form of RV pressure first then LV pressure wave form.other needle placed directly into Aorta , this wave we can measure gradient between aorta and LV cavity.
Regarding Approch for resection
we normally approch through Aorta, and resection of pappilary muscle upto apex has been done though this approch only.
pre operative planning, adequate spending of time intraoperativly for resection is important for good longterm outcome .
we have attached preoperative echo and post operative echo at 7 dayshows wide open LV cavity .
Thanks for the video. However, a close-up view is mandatory for the observer. The actual tricky parts of the operation cannot be well seen. Other than actual and accurate intraoperative pressure measurements using the classical transventricular puncture, the postoperative echo estimates would have also been of great help in this case.
Dr. Shah thank you for your answers. You are telling us that through a trans-aortic approach you are able to resect the papillary muscles up to the apex? How long is your knife handle? I would be very careful in resecting papillary muscles during a myectomy!
Changing title noticed. Appreciated. The only problem for the average observer is how to understand extended. How “extended”? It might be difficult to find accurate metrics for better understanding.
Dear Dr. Prashant, it is a well informed video. You have mentioned the tricks to assess the end point. thanks. Soma