TREATMENT

Learn about the many treatment options for hypertrophic cardiomyopathy.  Also understand the prognosis for patients with the condition depending on the presence or absence of obstruction.

Overview

There are many options for treating hypertrophic cardiomyopathy.  Treatment depends on whether there is obstruction of blood flow (hypertrophic obstructive cardiomyopathy or HOCM) and whether there are symptoms.  Initial treatment is with medication.  Surgical myectomy is the primary therapy for patients who are young or fail medical management.  Septal alcohol ablation (catheter-based approach) is reserved for patients who are not good surgical candidates.  In 2011, the American College of Cardiology & American Heart Association along with several other leading organizations, developed guidelines for the management of hypertrophic cardiomyopathy.

Treatment plan depends on :

2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy. Circulation.
2011; 124: e783-e831. Click to Enlarge.

Is there blockage of blood by the enlarged muscle?

Are there symptoms?

Any irregular heart beats (arrthymias)

Overall function of the heart

Age of the patient and ability to undergo surgery

History of fainting (passing out)

History of sudden death in patient or family

Medical Therapy

Medical treatments for hypertrophic cardiomyopathy include beta-blockers or calcium channel blockers to help relax the hypertrophied heart muscle and to slow the heart rate which allows for better heart function.  Patients with arrhythmias (irregular heartbeat) may require special medications to correct this.  Depending on the type of arrhythmia, other treatments may include blood thinners, a pacemaker, or an implantable defibrillator (to reduce risk of sudden death).

Alcohol Septal Ablation

In selected patients, Hypertrophic Obstructive Cardiomyopathy can be treated by alcohol septal ablation by causing necrosis of the obstructive muscle. It is usually reserved for patients at too high risk for surgery and who have a large coronary artery in that area of the septum. Click to enlarge.

Patients with severe obstructive hypertrophic cardiomyopathy and associated symptoms may require catheter-based on surgical interventions to relieve the obstruction.  In some patients, a catheter can be used to inject alcohol into the hypertrophied (enlarged) ventricular septum (which separates the left and right ventricles).  Not all patients have appropropriate anatomy that makes this possible.

Surgical Options

Ports used for totally endoscopic robotic surgery for Hypertrophic Obstructive Cardiomyopathy. Click to enlarge.

In totally endoscopic robotic mitral valve surgery, the septum is resected (myomectomy) through the aortic valve and the anterior leaflet is repaired with a large patch to enlarge the left ventricular outflow track on all sides. Click to enlarge.

Dr. T. Sloane Guy at the robotic console performing surgery. This allows him to see the anatomy of the hypertrophied septum and the often abnormal mitral valve very clearly with 3D magnified vision. This allows for very precise surgery. Click to enlarge.

A surgical myectomy can be performed to remove the muscle blocking the blood flow out of the heart.  A procedure on the mitral valve may also be required.  In many centers, this is done through a sternotomy.  In my practice, we usually do this using totally endoscopic robotic techniques.  You can see my other website for more details (roboticheartsurgeon.com).  However, we will give you a brief description here.  Basically, hypertrophic obstructive cardiomyopathy involves an abnormal relationship between the ventricular septum (enlarged and obstructive) and the mitral valve.  In my practice, we approach both in a totally endoscopic robotic procedure with 5 small incisions in the right chest (largest is 15 mm).  This allows for both septal myectomy and augmentation of the anterior leaflet to allow it to “catch the wind” and fly out of the way of the blood rushing out of the heart toward the aortic valve.  There are many potential advantages to this approach.  For one, it is very minimally invasive compared to procedures performed at other institutions (most do sternotomy).  More importantly, it allows incredible visualization of the septum from the aortic valve all the way to the apex (tip) of the heart.  One of the problems with sternotomy approaches (Morrow or Modified Morrow Procedure) is that it can be hard to resect muscle that is deep in the heart toward the apex due to limited.  I believe the endoscopic robotic approach through the mitral valve allows us to more clearly understand and fix the problem.

Video of Robotic HCM Surgery