Question about myectomy and small septal thickness

[Laoshur]

I mentioned in another entry that I had questioned, and my doctor agreed, that I was probably not a candidate for a myectomy or ablation due to the small size of my septum, even though I have a fairly large inducible gradient. He said that maybe I would need a mitral valve replacement. But I cannot figure out how that would help, since presumably the septum would then hit the new valve. I am wondering whether anyone else has been told this and what this would involve. This is not an urgent question because we agreed that this would be a last resort measure.

Any insights?
Rhoda

[Lisa Salberg]

Re: Question about myectomy and small septal thickness

This is a long answer...and my fingers dont have the time right now to explain it all. In short this may make sense - however smaller septums have done well with myectomy, although it is not very common to see.

call me if you have more questions.

Lisa

[Burton Borrok]

Re: Question about myectomy and small septal thickness

Hi Rhoda,
Frankly I’m pretty much at a loss as to the reasoning for a mitral valve replacement, unless the surgeon could place the new one in such a way as to avoid the interference from the septum, and solve or reduce the problem that way.

I just thought of something else which is probably right off the wall, but might also prove interesting. As I’m sure you remember from my previous postings, I picked up six stents last year. In an angioplasty the plaque is forced against the walls of the artery by a balloon, widening the pathway for the blood flow. In doing this the artery walls are stretched, and often fissures are created in the artery. The result looks like a swelling in the artery on the outside and a clear pathway for the blood flow on the inside, with the plaque being pushed into the added space in the artery.

This was the way it was done, starting about 1980. In a significant number of cases the weakened arterial wall would collapse, blocking the blood flow, and a by-pass operation would then be required. When I had my first angioplasty (now often referred to as heart catheterization) back in 1985, the angioplasty lab was immediately adjacent to the by-pass lab which was staffed and ready to go in the event I needed them.

Anyway, to offset this problem, stents, or little spring like devises, were invented to be placed at the site of the angioplasty and expanded to hold the artery open while it healed in its new form. These stents are permanently placed and left at the site.

Now your situation is that your septum is interfering with your mitral valve’s normal operation, but your septum is too thin for an ablation or myectomy. I wonder if it would be possible for an appropriately sized stent to be placed around the mitral valve, thus holding the septum back in that area and shielding the valve from interference. If it is possible, I think it would be an elegant solution.

The trick would be having a stent that could be depressed enough for placement, and yet would still be strong enough to shield the mitral valve effectively when in position. If this proved doable, you might just be the first one to benefit from the next step forward in treating this condition. It’s probably just a pipedream - - but then, isn’t that where advancements originate?
Burt

[mtlieb]

Re: Question about myectomy and small septal thickness

Hi Rhoda,

Prior to my myectomy four weeks ago, my septum had only ever measured between 1.5cm and 1.8cm, which is really not all that big as HCM'ers go. Unfortunately, i was one of those 'lucky' folks who for some unexplained reason had a large outflow gradient (144 mmHg) with a smaller septum.

At one point it was suggested to me that i might benefit from mitral valve surgery. The thinking was that if they couldn't reduce my septal thickness by myectomy, then they would simply make the mitral valve fit better with the septum. This would essentially have the same effect as myectomy, reducing the outflow gradient through the mitral valve. It's not an unusual proposal for an HCM'er with a large gradient but relatively small septum.

However, when i went to see the good doctors at the Cleveland Clinic in May, i was told that not only was my septum plenty thick enough to perform a myectomy, but that i was actually an ideal candidate for it and would most likely see great results. This does in fact seem to be the case, i'm very happy to say. As it turned out, my mitral valve needed no adjustment whatsoever during the myectomy.

In my opinion, this is just one more reason to be evaluated at a major HCM center where they perform these types of procedures every day.

Hope this has been of some help to you,

Jim

[Laoshur]

Re: Question about myectomy and small septal thickness

Thanks for the responses. I will wait for now to see how whether the pacing helps and at least now I know something of my options if it does not.

Rhida