Dr. Sushant Srivastava
Director & Sr. Consultant
Cardiothoracic & Vascular
Surgery, BLK Heart Centre
BLK Super Speciality
Hospital, New Delhi

Hypertrophic Obstructive Cardiomyopathy is a serious condition in which there is progressive left ventricular outflow obstruction due to assymetrical hypertrophy of the interventricular septum. Abnormal movement of the anterior mitral valve leaflet when the ventricle is ejecting can increase the gradient. These patients are prone to ventricular arrhythmias and sudden death is also reported in certain cases. Treatment is medical, catheter-based septal ablation or surgical resection.

THE CASE

A 62-year old lady was admitted in BLK Super Speciality Hospital with progressive Angina on exertion for six months. She underwent transthoracic and transesophageal ECHO which revealed Asymmetrical Septal Hypertrophy with a narrowed left ventricular outflow, a calcified aortic valve with significant aortic stenosis and regurgitation. The total gradient across the LVOT and aortic valve was 70mm Hg. Coronary Angiography was normal.

THE PROCEDURE

A decision to operate upon the patient was made. She was counselled about the risk involved. The operation was conducted through a median sternotomy. The patient was placed on cardio pulmonary bypass. The aorta was opened obliquely and the diseased aortic valve was excised. The hypertrophied septum was seen bulging into the LV outflow tract.

A No. 15 blade was carefully inserted into the septum underneath the right coronary sinus end, advanced 2.5 cm towards the apex. A parallel incision was made 1 cm apart and the hypertrophic myocardium was resected. The LVOT opened up well, aortic valve replacement was done with a No. 18 ATS prosthetic valve. Weaning from bypass was uneventful and the post-operative gradient by TEE dropped to 24 mmHg.

THE RESULT

The operation was successful with the desired outcome. The recovery process was uneventful and the patient was discharged after proper observation.

Surgery for Hypertrophic Obstructive Cardiomyopathy is demanding and requires precision. Post operatively, a small risk of ventricular arrhythmias persists hence, the patient is advised to be on beta blockers. Symptomatic improvement is dramatic and the risk declines progressively.