Extended myectomy in hypertrophic obstructive cardiomyopathy

Classical myectomy is the gold standard therapy for patients with severely symptomatic hypertrophic obstructive cardiomyopathy. Extended myectomy provides a complete relief from dynamical obstruction and is most effective in the prevention of sudden cardiac death.

At Burjeel Hospital, seven patients underwent extended myectomy in the last 5 years.

Surgical technique

A detailed preoperative transesophageal echocardiogram done in the operation theatre. LVOT gradients were assessed both by TEE and simultaneous pressure recording of LV cavity and ascending aorta. All patients were operated while on cardiopulmonary bypass with cardioplegic arrest. A low transverse aortotomy was the incision of choice in all cases. No additional ventriculotomy done in any of these patients. The extent of the hypertrophy is assessed by visual inspection and digital palpation. The muscle mass suitable for myomectomy is clearly defined by classical incisions on the thickened LV septum. All precautions were taken not to damage the aortic annulus and the cusps. The incision was extended towards the LV apex to get complete relief of the obstruction. The excision of the muscle mass was also extended behind the insertion of the mural leaflet of the mitral valve. Almost always we tried to remove the muscle mass in total in single piece. LV cavity was thoroughly washed and inspected well. Both the papillary muscles were completely inspected and all hypertrophied trabeculae as well as hypertrophied papillary muscles were resected. Additional muscle band from the papillary muscle to the septum was found in one case and resected without damaging the papillary muscle.

Again, the LV cavity was assessed both visually and also by digital palpation. While coming off bypass, TEE helped to identify complete relief of the pressure gradient. Four patients had significant mitral regurgitation where leaflet plication was done with no significant post-operative mitral regurgitation. Post-operatively, none of these patients had aortic regurgitation or significant mitral regurgitation or septal perforation or conduction block. One patient had an iatrogenic perforation in the aortic leaflet, which was repaired by pericardial patch. All of them had significant reduction in the pressure gradient on postop TEE assessment. All these patients were regularly followed up by our cardiology team. Two of the patients required elective implantable defibrillator.

Conclusion

In our experience, with the technique of extended myectomy, sustained relief was achieved in surgically treated HOCM patients, without SAM or significant mitral regurgitation, at long-term follow-up. No patient had sudden cardiac death during follow-up till date. Referrals for HOCM surgical interventions are still restricted to severely symptomatic patients with significant LVOT gradients under basal conditions.

HOCM – PATIENT PROFILE

S.NoDate of SurgeryAge/Sex/NationalitySymptoms
124/05/201731, Male, BangladeshDyspnea, chest pain
210/01/201854, Female, PhilippinesExertional dyspnea, chest pain and dizziness3
310/03/201823, Female, PakistanExertional dyspnea4
402/00/201955, Male, SyriaExertional dyspnea5
503/10/202039, Female, IndiaFatigue, dyspnea6
612/10/202034, Male, IndiaExertional dyspnea7
717/07/202134, Male, BangladeshExertional dyspnea

HOCM – INTRAOPERATIVE DETAILS

S.NoLVOT-AO Gradient, TEESAMMR ProcedureAdditional Procedure
164 mmHgYesYesExtended myectomyMV repair2
280 mmHgNoYesExtended myectomyAortic and mitral valve repair3
390 mmHgYesYesExtended myectomyMV replacement * outsidesurgeon4
4100 mmHgYesYesExtended myectomyMV repair
565 mmHgYesYesExtended myectomyMV repair
6140 mmHgNoYesExtended myectomy
7100 mmHgNoYesExtended myectomy

Brom’s procedure in adult done by Brom’s surgeon

Supravalvular aortic stenosis in adult: the three-patch technique:

Supravalvular aortic stenosis is a rare congenital malformation seen in pediatric age group as a result of an abnormal thickening of the aortic wall. This entity in adult age is further rare and we report a case of successful repair (Brom’s procedure) in an adult.

Prof. Brom worked in the UAE as the head of the department of cardiac surgery in Mafraq Hospital. During this time, he had his coronary bypass surgery done by Dr. Y. A. Nazer. Prof. Brom is considered as the father of pediatric cardiac surgery.

Introduction

Congenital supravalvular aortic stenosis (SVAS) is an uncommon anomaly presented as a narrowing situated at the level of the sinotubular junction. An early diagnosis is necessary in order to avoid future complications. Surgical treatment should ideally be performed in infancy to prevent early aortic valve degeneration, coronary artery pathology and left ventricular hypertrophy.

Case history

A 36-year-old male expatriate foreign national who presented with shortness of breath and chest pain of one-year duration. He had a detailed cardiology workup and his transthoracic echocardiogram showed supraaortic stenosis with post stenotic dilatation of the ascending aorta.

Preoperative transesophageal echocardiogram showed a supraaortic gradient more than 100 mmHg with mild aortic regurgitation.

Surgical technique

Under cardiopulmonary bypass and cardioplegic arrest, the aorta is transected just above the stenosis. Intraoperative findings were severe narrowing of the sinotubular junction with thick aortic valve. Aortic valve is tricuspid and normal leaflets. Left coronary osteum shifted more towards the left side.

Three longitudinal incisions were made in each sinus of Valsalva and rectangular shaped glutaraldehyde treated autologous pericardial patches were sutured. Care is taken to design the correct size of the patch. We have taken all precautions to avoid commissural extension and possible aortic regurgitation. An enlargement of the distal ascending aorta is also done with another piece of autologous pericardium (modified Brom’s procedure, four-patch technique).

Both coronary ostea were inspected and were found normal. Aorta closed in two layers and came off bypass in stable hemodynamics. Post-operative transesophageal echocardiography showed no gradient across the LVOT and aorta and no aortic regurgitation. The patient had a smooth post-operative recovery and discharged on seventh post-operative day. He is back to his normal activities.

Discussion

The three-patch technique, designed by Prof. Brom, offered a new concept for restoration of the aortic tract that continues to be the ideal model to repair supravalvular aortic stenosis both in pediatric and adult age group. There are multiple advantages in this technique. It provides a more symmetric reconstruction, less distortion of the aortic root and the ascending aorta. Glutaraldehyde treated autologous pericardium provides a normal thickness vascular tissue. This technique is easier than the other techniques and the individual patches can be designed in such a way that aortic root restoration will be optimal.

Breast cancer surgeries

Breast cancer surgery is intended to remove cancerous cells from your breast. A treatment to install breast implants or reconstruct a breast from your own tissue (flap surgery) may be done at the same time or at a later date for people who want breast reconstruction.

The majority of stages of breast cancer are treated with surgery, including:

  • A high risk of breast cancer. People who have a high risk of breast cancer due to a strong family history of the disease, certain noncancerous breast biopsy results, or a gene mutation may choose to undergo a preventative (prophylactic) mastectomy with or without rapid breast reconstruction.
  • Non-invasive breast cancer that is If you have ductal carcinoma in situ (DCIS), you can have a lumpectomy followed by radiation therapy, or you can have a mastectomy with or without reconstruction.
  • Breast cancer in its early stages. Small breast cancers are usually treated with a lumpectomy or mastectomy, with or without reconstruction of the breast, followed by radiation and, in rare cases, chemotherapy, hormone therapy, or targeted therapy.
  • Breast cancers that are larger. Larger cancers may be treated by mastectomy, though chemotherapy, hormone treatment, or targeted therapy may be utilized beforehand to allow a lumpectomy to be performed. Radiation therapy, chemotherapy, hormone therapy, or targeted therapy may be suggested in addition to standard care.
  • Breast cancer that has progressed locally. Chemotherapy, hormone treatment, or targeted therapy are frequently used to reduce tumors that have spread to numerous lymph nodes and make surgery more successful. Mastectomy or lumpectomy, followed by radiation therapy, may be used to eliminate these malignancies.
  • Breast cancer that recurs. Additional surgery may be required to remove breast cancer that has returned after first treatment. It’s possible that other therapies will be suggested.

Note: * The information on this website is not meant to be used to diagnose health conditions or to replace legitimate medical advice.

Dr. Toufic Ata
Consultant Laparoscopic Bariatric and General Surgery

What is Breast Cancer?

Breast cancer begins in the breast and spreads to other parts of the body. When cells multiply uncontrollably, cancer develops.

It’s critical to remember that the majority of breast lumps are benign and not cancerous (malignant). Breast tumors that aren’t cancerous are abnormal growths that don’t spread outside of the breast. Although benign breast lumps are not life threatening, they can raise a woman’s risk of developing breast cancer. Any lump or change in your breast should be evaluated by a health care specialist to see if it’s benign or malignant (cancer) and if it’ll alter your cancer risk in the future.

Where does breast cancer begin?

  • The ducts that deliver milk to the nipple are where most breast tumors start (ductal cancers)
  • Some of them begin in the glands that produce breast milk (lobular cancers)
  • Other kinds of breast cancer, such as phyllodes tumor and angiosarcoma, are less common.
  • A small percentage of breast tumors begin in other tissues. Sarcomas and lymphomas are malignancies that aren’t typically thought of as breast cancers.

Types of breast cancer

Breast cancer comes in numerous forms, the most frequent of which are ductal carcinoma in situ (DCIS) and invasive carcinoma. Others, such as phyllodes tumors and angiosarcoma, are rare.

Breast cancer cells are examined for proteins termed estrogen receptors, progesterone receptors, and HER2 after a biopsy. In the lab, the tumor cells are also examined closely to determine the grade. Treatment options can be influenced by the specific proteins discovered and the tumor grade.

Learn more about breast cancer in the next blog.

Note: * The information on this website is not meant to be used to diagnose health conditions or to replace legitimate medical advice.

Dr. Toufic Ata
Consultant Laparoscopic Bariatric and General Surgery

Advices for feeding underweight child

It is preferable to eat 3 main meals and 2 snacks between them. Main meals are with the family and snacks are fresh vegetables four hours before lunch.

Seafood products (fish or shrimp) should be eaten at least twice a week (friedor grilled).

Eat plenty of fiber (such as vegetables and fruits) to avoid constipation. And treat constipation, if any.

To avoid eating a lot of cabbage, as too much cabbage negatively affects the thyroid gland.

Sleep early in a quiet and dark place is necessary for proper growth.

It is preferable to eat well-cooked liver (from beef or lamb) at least once a week.

It is prohibited to serve all kinds of sweets four hours before lunch. But ice cream can be given four hours after lunch, and French fries can be eaten at home for lunch.

It is forbidden to use yogurt with added flavors or fruits (because sugar is added to it during manufacture), but full-fat yogurt can be used without additives and a type of fruit can be added to it and blended at home.

Olive oil should be added to salads and other foods because it contains important healthy compounds.

All types of canned goods and ready-made chips and pre-made crackers, as well as any juices, are prohibited at any time.

Children should not be allowed to drink more than two cups of milk per day as this leads to reduce food intake at meals.

Avoid drinking cold or iced water after eating, as it causes indigestion.

All soft drinks, tea and coffee are prohibited.

To stimulate appetite, babies need to exercise and play daily.

Toys, books, or television should not be allowed during meals, as this distracts children from eating.

Meals should be fun times for the family and children should not be forced to eat. It is difficult for a child to eat while sad or crying. Eating with the family should be an enjoyable experience that increases a child’s appetite.

And it is preferable to do some tests for the child to rule out some medical problems such as iron deficiency.

Vitamins can be given to a child under the supervision of a doctor.

In the event that the doctor requests the use of high-calorie milk, it is preferable to take it after lunch and in the evening (because if the child consumes it in the morning, he may not eat well, breakfast and lunch), and the milk powder must be dissolved in the amount of water specified on the package. You should check child weight with your doctor.

Prefers higher-calorie foods (such as foods fried in butter and peanut butter)

Note: * The information on this website is not meant to be used to diagnose health conditions or to replace legitimate medical advice.

Dr. Mohamed Abbas
Specialist- Pediatrics & Neonatology

Iron Deficiency treatment

How is iron deficiency treated?

By taking iron medicine (syrup or tablets) until iron deficiency is treated and iron stores in the body are filled.

Iron-rich foods:

  • Meat: beef or lamb, especially liver
  • Poultry: chicken, turkey, duck, especially liver
  • Fish, especially sardines and anchovies
  • Green Vegetables
  • Legumes like beans, peas, and beans

Important Notes:

  • Liver is the best source of iron.
  • Iron absorption from plant foods is more difficult than from animal foods.
  • Lemon and orange help iron absorption.
  • To help iron absorption, vitamin C can be taken with iron (after doctor consultation).
  • Tea and coffee are strictly prohibited.
  • Do not take iron medicine with (antacids or calcium) at the same time. Space them for 2-3 hours to get the full benefit of each medication.

The following foods should be avoided for at least two hours before and after consuming iron: cheese, yogurt, eggs, milk, spinach, bread, rice, pasta, whole grains and bran.

Therefore, it is preferable to take iron medicine three hours after lunch with lemon or orange juice and not to eat anything after it for two hours.

Note: * The information on this website is not meant to be used to diagnose health conditions or to replace legitimate medical advice.

Dr. Mohamed Abbas
Specialist- Pediatrics & Neonatology

Chickenpox

The varicella-zoster virus is responsible for chickenpox. It generates a rash with small, fluid-filled blisters that is irritating. People who have never had chickenpox or who have not been vaccinated against it are highly contagious. Children can now be protected against chickenpox with the use of a vaccination. The Centers for Disease Control and Prevention in the United States recommends routine vaccination (CDC).

Symptoms

Chickenpox infection causes an itchy blister rash that emerges 10 to 21 days after exposure to the virus and lasts about five to ten days. The following signs and symptoms may emerge one to two days before the rash:

  • Loss of appetite
  • Headache
  • Fever
  • Tiredness and a general feeling of being unwell (malaise)

The chickenpox rash goes through three stages after it appears:

  • Papules are raised pink or red pimples that appear over a period of time.
  • Vesicles are small fluid-filled blisters that form in about a day and then burst and leak.
  • Crusts and scabs form on top of the damaged blisters and take several days to heal.

Causes

The varicella-zoster virus causes chickenpox infection. Direct touch with the rash can cause it to spread. When a person with chickenpox coughs or sneezes and you inhale the air droplets, it can spread.

Prevention

The best approach to avoid chickenpox (varicella) is to get vaccinated. According to the CDC, roughly 98 percent of persons who take both of the required doses of the vaccine are completely protected against the virus. When the vaccine does not provide complete protection, the severity of chickenpox is greatly reduced.

Note: * The information on this website is not meant to be used to diagnose health conditions or to replace legitimate medical advice.

Dr. Ahmed Mohamed Abdelaal
Consultant – Pediatrics

Breast cancer- What to expect

Breast cancer surgery is a crucial part of breast cancer treatment that entails surgically removing the malignancy. Chemotherapy, hormone therapy, targeted therapy, and radiation therapy are all options for treating breast cancer.

Breast cancer surgery can comprise a variety of procedures, including:

  • The entire breast is removed in surgery (mastectomy)
  • A piece of the breast tissue is removed during surgery (lumpectomy)
  • Surgery to remove lymph nodes in the area
  • After a mastectomy, surgery is performed to reconstruct the breast.

Risk

Although breast cancer surgery is a relatively safe operation, it does include a minor risk of consequences, which include:

  • Bleeding
  • Infection
  • Collection of fluid at the operative site (seroma)
  • Pain
  • Permanent scarring
  • Loss of or altered sensation in the chest and reconstructed breasts
  • Wound healing problems
  • Arm swelling (lymphedema)
  • Risks related to the medicine (anesthesia) used to put you in a sleep-like state during surgery, such as confusion, muscle aches and vomiting

What’s after the surgery?

  • You should expect to be brought to a recovery room where your blood pressure, pulse, and respiration will be monitored.
  • Cover the operation site with a dressing (bandage).
  • Underarm soreness, numbness, and a pinching sensation are all possible symptoms.
  • Get instructions on how to take care of yourself at home, including how to care for your incision and drains, how to recognize signs of infection, and how to follow activity limitations.
  • Discuss when you should start wearing a bra or a breast prosthesis with your healthcare provider.
  • Prescriptions for pain relievers and potentially antibiotics will be supplied to you.
  • Return to your regular eating routine.
  • After surgery, shower the next day

Note: * The information on this website is not meant to be used to diagnose health conditions or to replace legitimate medical advice.

Dr. Toufic Ata
Consultant Laparoscopic Bariatric and General Surgery