2024 FSA Podium and Poster Abstracts

P057: ANESTHETIC MANAGEMENT OF A 49 YEAR OLD WOMAN WITH HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY UNDERGOING SEPTAL MYECTOMY
Harshvardhan Rajen, MD; Oleg Desyatnikov, DO; Hani Murad, MD; Gian Paparcuri, MD; HCA Florida Kendall Hospital

Our patient is a 48 year old woman with a past medical history of hypertrophic obstructive cardiomyopathy that was diagnosed at 17 years old, who was having near constant chest pressure and palpitations. She also had a history of ventricular tachycardia with an implantable cardioverter defibrillator placed in 2009 and replaced in 2014. Preoperative transesophageal echocardiogram revealed ejection fraction of 70%, mild mitral regurgitation, and mild to moderate tricuspid regurgitation. The planned surgical procedure is a septal myectomy of the interventricular septum.

The patient was induced with general anesthesia and precautions taken to minimize any exacerbation of a left ventricular outflow tract obstruction caused by the thickened septal muscle. Normotension was maintained throughout the initial phase of the surgery with volume resuscitation in order to maintain adequate preload. Avoidance of sympathetic stimulation during induction and incision was minimized in order to avoid hemodynamic collapse that could be caused by tachycardia, decreased afterload, or arrhythmia. After the myectomy was completed the intraoperative transesophageal echocardiogram demonstrated improvement of blood flow through the left ventricular outflow tract, reduction of left ventricular outflow obstruction and near resolution of the mitral regurgitation that was noted previously. She was transported to the intensive care unit for further monitoring and her postoperative course was uneventful and she was discharged home on postoperative day 6.

With the advent of newer medical interventions, the need for high risk invasive surgical procedures has typically been greatly reduced. Another treatment method that has emerged to treat left ventricular outflow obstruction has been alcohol septal ablation. There are not many studies regarding the differences in long term outcomes between surgery and ablation. However, there is a retrospective cohort study that compares patients who underwent surgical myectomy against alcohol septal ablation. They showed that there was no difference in survival, but freedom from reintervention and early and late reduction of left ventricular outflow tract gradient are superior in patients undergoing septal myectomy. The choice of intervention should be a discussion among, patient, surgeon, and cardiac team to optimize the benefits of each procedure to each individual.