17461 Septal Myectomy

Overview

A septal myectomy is heart surgery. It removes a small piece of extra-thick heart muscle from the septum — the wall that separates the two lower chambers of your heart. Doctors do this surgery most often for hypertrophic cardiomyopathy, or HCM. In HCM, the heart muscle grows too thick. Sometimes the thick muscle blocks the path that blood takes out of the heart. Removing that extra muscle opens the path and helps blood flow more freely. It can also help the heart's mitral valve close better, which lowers leakage. The surgery is done under general anaesthetic, which means you will be asleep and feel nothing during the operation.

Septal myectomy is an uncommon operation. Hypertrophic cardiomyopathy affects roughly 1 in 500 people, and only a small number of those people ever need this surgery. Because it is uncommon, it is best done at a centre with a specialist team who do it regularly.

It is done in people of all ages who have a thickened heart muscle that is blocking blood flow and causing symptoms. Many are younger or middle-aged adults. It is sometimes done in children and teenagers, and sometimes in older adults, but the decision is always made case by case by a specialist heart team.

Symptoms

Common symptoms

• Breathlessness when walking, climbing stairs or exercising
• Chest pain or tightness, often worse with effort
• Feeling dizzy or light-headed
• Fainting or nearly fainting, especially during or after exercise
• A pounding, fluttering or irregular heartbeat (palpitations)
• Unusual tiredness or low energy
• These are symptoms of the heart condition that the surgery aims to relieve — they are not caused by the operation itself.

Symptoms in children

• Poor feeding and slow weight gain in babies
• Breathlessness or rapid breathing during feeds or play
• Sweating more than expected, especially when feeding
• Tiredness or lagging behind other children in activity
• Fainting or dizziness during exercise or sport
• In children, surgery is considered only by a specialist children's heart team, and many children are managed with medicines and monitoring first.

Symptoms in older adults

• Breathlessness and tiredness that come on more easily than before
• Chest tightness with everyday tasks
• Palpitations or a new irregular heartbeat
• Dizziness or falls
• In older adults, it is important for doctors to check whether the thickening comes from HCM or from another cause, such as long-standing high blood pressure or a build-up of protein in the heart called amyloid. These are treated very differently.
• Recovery after surgery can take longer in older adults, and other health conditions are taken into account.

Causes

Main causes

• Septal myectomy is a procedure, so it does not have a 'cause' in the usual sense. It is done to treat a thickened heart muscle that is blocking blood flow.
• The most common reason is hypertrophic cardiomyopathy (HCM), which is usually passed down in families through changes in genes.
• Less often, thickening is linked to long-standing high blood pressure or a narrowed aortic valve, or to a condition called amyloid, where protein builds up in the heart. Doctors check for these before planning surgery.

Risk factors

• A family history of hypertrophic cardiomyopathy, or of sudden cardiac death in a young relative
• A known gene change linked to HCM
• Long-standing untreated high blood pressure (for other forms of muscle thickening)
• For the surgery itself, risks are higher if you are older, have other heart or lung conditions, or have had previous heart surgery — your surgeon will talk these through with you

When to see a doctor

See a doctor urgently if:

• You faint or nearly faint, particularly during exercise
• Your breathlessness gets worse quickly, or you cannot finish your usual activities
• You have new chest pain with effort
• You notice a fast or irregular heartbeat that lasts or makes you feel unwell
• Your ankles or legs swell, or you gain weight quickly without changing your eating

Book a routine appointment if:

• Your symptoms are getting slowly worse over weeks or months
• You want to discuss whether surgery might be an option for you
• Someone in your family is found to have hypertrophic cardiomyopathy — ask about screening for yourself
• You have questions about medicines, exercise or sport, or pregnancy planning with HCM

Diagnosis

The decision about surgery starts with a full heart assessment. A cardiologist (heart specialist) will ask about your symptoms, examine you, and arrange heart tests. These show how thick the muscle is, whether blood flow is blocked, and how well your heart valves and rhythm are working. Your case is then usually discussed by a team of specialists — heart doctors, surgeons and imaging experts — before surgery is offered. They weigh up your symptoms, your test results and your own preferences.

Tests that may be done

• Echocardiogram — an ultrasound scan of the heart that shows muscle thickness, the blockage and valve function
• Electrocardiogram (ECG) — a tracing of the heart's electrical activity
• Ambulatory ECG — a small monitor worn for a day or more to catch irregular rhythms
• Exercise or stress test — watching your heart while you walk or cycle, sometimes with breathing and heart-rate monitoring
• Cardiac MRI — a detailed scan that shows the heart muscle and any scarring
• Blood tests — to check general health and to rule out other causes of thickening
• Genetic counselling and a genetic blood test — to look for an inherited cause and to help test relatives
• Cardiac catheterisation — a thin tube passed to the heart to measure pressures, if needed
• Pre-operative checks, such as a chest X-ray and dental review, before surgery

What to expect at your appointment

The tests are mostly painless. Ultrasound and ECG are quick and done in a clinic. MRI involves lying still in a scanner for around half an hour. A stress test means walking on a treadmill or pedalling while your heart is watched. Before surgery you will meet the surgeon and the anaesthetist, who will explain what will happen, the risks, and how to prepare. You will be asked not to eat or drink for a set time before the operation, and you will be given clear instructions about your usual medicines.

Treatment

Treatment for a blocked, thickened heart muscle usually starts with medicines and careful monitoring. If symptoms continue despite medicines, the specialist team may suggest a procedure to open the blood flow. Septal myectomy is the main surgical option. Another option is alcohol septal ablation, where a small amount of pure alcohol is injected through a tube to shrink part of the thickened muscle. A pacemaker is sometimes used in certain people. An implantable defibrillator may be advised separately to protect against dangerous heart rhythms. The right choice depends on your heart, your symptoms and your team's experience.

Self-care at home

• Stay as active as your body allows before surgery — gentle walking is usually helpful unless your team advises otherwise
• Take your heart medicines exactly as prescribed, and never stop or change them without asking your team
• Stop smoking if you can — your team can point you to free help
• Cut back on alcohol, and avoid getting dehydrated, especially in hot weather
• Ask your team what to do about caffeine, saunas, hot tubs and very heavy lifting
• Write down your questions and take someone with you to appointments
• Arrange practical help at home for the first few weeks after surgery
• After surgery, do your breathing exercises as shown, keep the wound clean and dry, and follow your team's lifting advice while your breastbone heals

Medical treatments

Doctors describe heart medicines that help the thickened muscle relax and fill properly, and medicines that control blood pressure and heart rhythm. These can improve symptoms but do not remove the blockage. Your team will review your medicines regularly and adjust them to your needs. If medicines are not enough, they may discuss a procedure or surgery. Your pharmacist can explain what each medicine is for and how to take it, and you should always ask before adding any over-the-counter product, including herbal remedies.

When is surgery considered?

Septal myectomy may be offered when symptoms such as breathlessness, chest pain or fainting continue despite medicine, and tests show a clear blockage of blood flow out of the heart. It may also be considered in some people with valve problems, or when other treatments are not suitable. The decision is made with you by a specialist team who do this operation regularly. Do ask about their experience, the risks, alternatives and what recovery will look like.

Living with this condition

Most people spend around a week in hospital after surgery, though this varies. You will be up and walking with help within a few days. At home, you will feel tired at first and your breastbone (if it was opened) needs about six to eight weeks to heal. Many people take around six to twelve weeks off work, depending on the job and how they recover. Gentle activity helps, but heavy lifting, pushing and straining are avoided at first. Most people notice easier breathing and more energy within weeks to months.

Lifestyle tips

• Build activity back slowly, using a walking plan or a cardiac rehabilitation programme if one is offered
• Follow your team's advice about strenuous exercise and competitive sport — this matters more if you still have HCM
• Avoid heavy lifting and straining until your team says it is safe
• Keep to regular heart check-ups, as thickening in other parts of the heart can still matter over time
• Stay well hydrated and avoid binge drinking
• Let any doctor, dentist or nurse know you have HCM and have had heart surgery
• Tell your close relatives that HCM can run in families so they can ask about screening

Diet and exercise

There is no special diet for HCM, but a balanced, heart-healthy way of eating helps — plenty of vegetables, fruit, wholegrains, beans, fish and lean protein, and less salt, processed food and sugary drinks. Ask your team whether you need to watch salt. Alcohol in large amounts can trigger irregular heart rhythms, so keep it low or avoid it. Exercise is encouraged, but the type and amount should be agreed with your team — walking, swimming gently and static cycling are common starting points after recovery.

Mental health and emotional wellbeing

It is very common to feel worried, and some people feel low or frightened, especially while waiting for surgery or in the early weeks afterwards. You may worry about your heart rhythm, your family, or getting back to normal life. These feelings usually ease, but they deserve attention. Talk to your heart team, your family doctor, or a counsellor. If you ever feel hopeless, or have thoughts of harming yourself, please reach out for crisis support straight away — contact your local emergency services or a crisis line in your country, and tell someone you trust.

Prevention

The inherited form of heart muscle thickening cannot be prevented, and no lifestyle change removes the extra muscle. What you can do is reduce the chance of complications: keep blood pressure well controlled, stay active within your team's advice, avoid binge drinking, treat sleep problems such as heavy snoring, and keep to your heart check-ups. If you have HCM, avoiding very strenuous straining and following advice about competitive sport also matters.

Vaccines

Ask your doctor which routine vaccinations you need, including flu and pneumonia vaccines if they are recommended for you. Good general prevention of infections helps protect your heart, and your team can advise on timing around surgery.

Screening programmes

If someone in your family has HCM, close relatives — parents, siblings and children — should be offered screening with an ECG and heart ultrasound, and sometimes a genetic test. Screening often starts in childhood or the teenage years and is repeated over time, because changes can appear later. Screening does not mean something is wrong; it means finding anything early, when it is easier to manage.

Complications

If left untreated

• Symptoms such as breathlessness, chest pain and dizziness can become limiting and affect daily life
• Some people develop irregular heart rhythms, including atrial fibrillation, which raises the risk of stroke
• A small number of people with HCM are at risk of dangerous heart rhythms that can cause sudden cardiac arrest — your team will assess this risk and discuss protection with you
• In some people, the heart can enlarge and weaken over time, leading to heart failure
• Like any major heart operation, septal myectomy has its own risks, including bleeding, infection, an irregular heartbeat, a small chance of needing a pacemaker, and a very small risk of stroke or death. Your surgeon will explain your personal risks clearly.

Long-term outlook

The outlook after septal myectomy is generally good. For most people, the blockage is relieved and symptoms improve clearly, often for many years, and many return to a near-normal level of activity. Recovery takes weeks rather than days, and some people still need heart medicines and regular check-ups afterwards. Your specialist team will keep watching your heart, your rhythm and your family's screening needs, so you are supported at every stage rather than left to manage alone.

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