1b) Our distinguished faculty is Hartzell Schaff, MD, @HSchaffMD, Cardiovascular Surgeon @MayoClinic, and President, American Association for Thoracic Surgery @AATSHQ. Also contributing is Fernando Juarez-Casso @FernandoM_JC.#FOAMed #cardiotwitter @MedTweetorials #HCM pic.twitter.com/NascPodMM5
— cardio-met (@cardiomet_CE) May 18, 2023
2a) Options for #medical mgmt of #HCM are increasing (earn CE/#CME credit at https://t.co/7KtfmhxiaX) & may provide symptomatic relief for many patients. Typical symptoms of obstructive HCM inc exertional #dyspnea, #angina, #palpitations, #syncope, & sudden cardiac death #SCD.
— cardio-met (@cardiomet_CE) May 18, 2023
2c) What is that surgery? Septal #myectomy involves excision of a portion of hypertrophied septal muscle to relieve dynamic left ventricular outflow tract (#LVOT) obstruction in patients with hypertrophic cardiomyopathy #HCM
— cardio-met (@cardiomet_CE) May 18, 2023
4) Successful operation provides more complete #hemodynamic & symptomatic relief than currently available medical therapy & may be performed in patients of any age or severity of symptoms.https://t.co/vgIGd2UOF0
— cardio-met (@cardiomet_CE) May 18, 2023
🔓 https://t.co/kmFlyWyrse
5b) Septal myectomy in symptomatic pts w/latent obstruction ➡️ similar survival & sx relief vs pts with severe resting gradients preop. See % of pts w/NYHA class I or II status preop & during follow-up after septal myectomy:
— cardio-met (@cardiomet_CE) May 18, 2023
🔓https://t.co/iN0eXosIyEhttps://t.co/H3dre8XwOv pic.twitter.com/UIPxHTJl8M
7) Young asymptomatic pts w/subaortic gradients >100 mmHg may also be candidates for surgical treatment, which is associated with low operative mortality and may reduce the risk of sudden cardiac death #SCD.
— cardio-met (@cardiomet_CE) May 18, 2023
9a) Some pts w/obstructive #HCM may experience (similar to #aortic valve #stenosis) shear stress changes due to the outflow obstruction. This is mediated by #vonWillebrand factor ⬆️ #platelet dysfunction and may result in ⬆️ #gastrointestinalbleeds.
— cardio-met (@cardiomet_CE) May 18, 2023
10a) The decision to undergo surgical treatment should involve #shareddecision-making with the patient. Some may prefer a prolonged trial of medical therapy, but others may choose to proceed with septal myectomy. pic.twitter.com/u9D62o2uyb
— cardio-met (@cardiomet_CE) May 18, 2023
11a) #Septal #myectomy is a well-established procedure in current practice, usually reserved for patients with symptomatic #HCM who are unresponsive to medical therapy. pic.twitter.com/B95UnaDhZF
— cardio-met (@cardiomet_CE) May 18, 2023
12a) For pts with isolated #subaortic obstruction, an extended transaortic #myectomy is the standard procedure. In figure below (tweet 12b), the white endocardial plaque demarcates the zone of contact between . . .
— cardio-met (@cardiomet_CE) May 18, 2023
13a) Results with this approach are historically positive: nearly all pts w/ obstructive #HCM experience sig improvement in functional status post adequate septal myectomy, which ⬇️ exertional #dyspnea, #chestpain, #syncope.https://t.co/SqidnV8py1
— cardio-met (@cardiomet_CE) May 18, 2023
13c) Septal #myectomy ➡️ relief of gradients also ⬇️late occurrence of arrhythmias, improves #LVdiastolic filling & function, restores ability to ⬆️ stroke volume.
— cardio-met (@cardiomet_CE) May 18, 2023
🔓 https://t.co/403NQKM2fk
🔓 https://t.co/E0SNeojBBL
13e) After septal #myectomy
— cardio-met (@cardiomet_CE) May 18, 2023
👉 #LBBB common but does not influence late survival
👉complete #heartblock in ~9%, less common in experienced ctrs
👉rarely, again related to experience, #VSD
👉#aortic valve injury may➡️late AVR, 🔓 https://t.co/x2H1Ro6dnX
14) Patients with obstructive #HCM who undergo transaortic septal #myectomy appear to have better long-term survival rates compared to non-operated patients with LVOT obstruction, and are similar ♂️ & ♀️, tho women often at higher risk pre-op.
— cardio-met (@cardiomet_CE) May 18, 2023
🔓 https://t.co/XwLDdZjjpt pic.twitter.com/lVK3zCxCsz
15b) … using the #cardiotomy sucker to improve exposure. The fibrous scar on the #endocardial surface shows the contact zone between the hypertrophied #septum & the #papillary muscle. This contact lesion is the region from which the intracavitary pressure gradient originates. pic.twitter.com/0hHgikcjGV
— cardio-met (@cardiomet_CE) May 18, 2023
16b) Apical aneurysms are assoc'd w/⬆️ risk of sudden cardiac death #SCD, ventricular #arrhythmias, #heartfailure, ventricular #thrombus formation, & #mortality, so they should be excised during midventricular myectomy. pic.twitter.com/6YvsdiD9rr
— cardio-met (@cardiomet_CE) May 18, 2023
17b) The most common postop complications after combined transaortic & transapical septal myectomy in patients with complex hypertrophic cardiomyopathy are #AFib (25.6%) & prolonged ventilation (7.0%).
— cardio-met (@cardiomet_CE) May 18, 2023
🔓 https://t.co/6TdymnPVCz
18b) This approach can also help repair apical #aneurysms common in patients with midventricular obstruction.
— cardio-met (@cardiomet_CE) May 18, 2023
19b) Long-term survival rates after midventricular myectomy are comparable to those of a similarly aged and gender-matched population in the 🇺🇸 in the initial 10 years postop, but then decrease.
— cardio-met (@cardiomet_CE) May 18, 2023
🔓 https://t.co/G50YfiHjtC pic.twitter.com/sRzOncAsqS
20a) In patients with severe symptomatic #diastolic #heartfailure due to extensive apical hypertrophy, a transapical #myectomy to increase the #LV cavity size and improve diastolic function is an effective treatment option.
— cardio-met (@cardiomet_CE) May 18, 2023
21a) #Atrialfibrillation is an important consideration during preop patient evaluation. #AF is present in approximately 20% of pts who undergo surgical septal #myectomy for obstructive #HCM.
— cardio-met (@cardiomet_CE) May 18, 2023
🔓 https://t.co/RaTIBHLqDW
🔓 https://t.co/08ECus0FQJ pic.twitter.com/R079658djy
21c) Ablation of #preop AF should be performed at the time of septal #myectomy to reduce risk of postop complications such as arrhythmias & stroke.
— cardio-met (@cardiomet_CE) May 18, 2023
🔓 https://t.co/Gx8miOLDbM
22b) An extended transaortic myectomy is the standard procedure for pts w/ isolated subaortic obstruction. Transapical #myectomy is typically performed for pts with long or midventricular obstruction.
— cardio-met (@cardiomet_CE) May 18, 2023
22d) In pts w/ severe symptomatic diastolic #heartfailure due to extensive apical hypertrophy, a transapical #myectomy to increase the #LV cavity size & improve diastolic function is an effective treatment option.
— cardio-met (@cardiomet_CE) May 18, 2023
23b) . . . offering patients with all types of #HCMexcellent symptom relief, functional improvement, low morbidity and mortality rates, and long-term survival.
— cardio-met (@cardiomet_CE) May 18, 2023
24b) It's ≥50 mmHg at rest. You got that, right?
— cardio-met (@cardiomet_CE) May 18, 2023
What is the most common arrhythmia associated with #HCM, both preop and postop?
25) And you made it! You just earned 0.5hr 🆓 CE/#CME, & picked up some surgical knowledge as well. Go to https://t.co/yvbVXSaD9C to claim your certificate, & FOLLOW US for more expert-led #MedEd! @HSchaffMD & @FernandoM_JC thank you for joining us!
— cardio-met (@cardiomet_CE) May 18, 2023