When medication and devices don’t fully control symptoms, surgery might be considered as an option.
Surgery for implanted devices
A pacemaker is usually fitted as a day case using local anaesthetic and can take about one hour to be implanted and checked. The pacemaker is usually fitted on your left side, as this is closer to the heart and allows the wires to be inserted easily.
After your pacemaker has been fitted you will have a small wound which is likely to have been closed with dissolvable stitches or glue.
- You will be advised to avoid lifting your arm on the pacemaker side above your shoulder and to avoid strenuous activities for 4-6 weeks after your pacemaker has been implanted, this is to help prevent the leads moving following implantation.
- You will also be advised not to drive for 4 weeks post-implantation Before you leave hospital you will be given a pacemaker identification card with the details of your device and you should keep this card with you at all times in case of an emergency.
- You will also be given an appointment to attend the hospital so that your pacemaker can be checked by a specialist.
This device is put in whilst you are under a general anaesthetic, or when you are sedated and under a local anaesthetic. Following the procedure, you are likely to remain in hospital overnight following the implant (to check on your recovery), and have an x-ray to ensure that the ICD is correctly in place.
The ICD leads are inserted through a small incision just under your collar bone on the left side of your chest into the right side of the heart. An x-ray is used to guide the leads into place. If your device has a single lead, it will be placed in the ventricle. If it has two, one sits in the ventricle and one in the atria. The leads are attached to the heart muscle to keep them in place.
The generator is then implanted. This is usually located in the left side of the upper chest, and sits in a small space under the skin or muscle (sometimes referred to as a ‘pocket’). The generator is then connected to the lead (or leads).
Once the generator and leads are in place and connected, the device will be ‘programmed’. This involves testing that the device works by bringing on an arrhythmia using electrical impulses, and checking that the device responds to treat these arrhythmias. It will also be programmed to recognise natural increases in your heart rate, such as when you are active or exercising. This is important as it means that the device can be adjusted and programmed to meet your needs.
The wound is closed with stitches and covered with a dressing.
You can ask your hospital for further information about the procedure for this, as it may vary from one hospital to another.
Alcohol Septal Ablation
In some patients with hypertrophic cardiomyopathy, thickening of the heart muscle can obstruct blood flow out of the heart. This can sometimes cause a change in symptoms and some people will be advised to have an alcohol septal ablation.
Alcohol Septal Ablation ( ASA) is a less invasive procedure than a surgical myectomy. During this procedure, alcohol is injected into a heart artery this causes the area of thickened heart muscle to reduce. This improves blood flow through the heart.
Septal myectomy surgery is sometimes offered as an alternative procedure for some people with HCM as both procedures reduce the thickness of the septum. Your cardiologist should advise you which procedure would be best for you.
A small number of people may need to have a heart transplant. This involves removing the failing heart and replacing it with the heart from a donor. Assessment normally takes place in hospital over 2 of 3 days.
Most patients accepted on to a transplant waiting list have an expected survival of 50 per cent or less over the following two years. Survival after a heart transplant is 80 per cent, 70 per cent and 55 per cent at one, five, and ten years respectively.
Some patients improve significantly and may be able to come off the transplant list and continue on medication.
The surgery averages about four hours. The operation removes most of the heart, although a small cuff of the upper chambers may be left to attach the new heart onto. After surgery, you can expect to be awake in a day and to spend a day or two in the intensive care unit.
You will spend an average of three weeks in hospital and will be able to learn about your immunosuppressive drug combination, and how you can monitor yourself at home for complications. You will receive physiotherapy, and be given advice on diet and lifestyle changes. Most people take several months to reach full fitness. During the first year you will need frequent hospital visits for tests including biopsies of your heart to look for evidence of rejection. The biopsy is an outpatient procedure (under local anaesthetic) and takes about half an hour.
Depending on your occupation you may return to work three to six months after a heart transplant. Most people enjoy an excellent quality of life and rarely need admission to hospital other than for planned investigations. While a second transplant is possible, it is an option that is available to very few.