A patient with hypertrophic cardiomyopathy undergoing non-cardiac surgery

A 73 year old woman with hypertension who presented with exertional chest pain was found to have a harsh ejection systolic murmur, with features of left ventricular hypertrophy on electrocardiography. Coronary angiography showed normal coronary arteries and transthoracic echocardiography detected concentric thickening of the left ventricular wall, with hyperdynamic systolic function. These findings were thought to be secondary to hypertension, which was managed with ramipril 10 mg and amlodipine 5 mg.

Three years later she returned with breathlessness, and further transthoracic echocardiography suggested severe obstruction of the left ventricular outflow tract owing to systolic anterior motion of the anterior mitral leaflet, with an outflow gradient of up to 160 mm Hg. She was diagnosed with hypertrophic cardiomyopathy and was managed with bisoprolol 5 mg. Her symptoms improved and no arrhythmias were found on 24 hour electrocardiography (figure⇓).

Two years later she developed painful abdominal distension with anaemia. Computed tomography demonstrated bilateral ovarian masses. She was listed for a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The indication for surgery was symptom relief and suspected cancer.