Myotomy, commonly known as unroofing surgery, is the first-line surgical treatment for<unk> s. It is the only treatment that actually removes the<unk>  itself, releasing the artery from compression. Unroofing surgery today is done via open heart (sternum), thoracotomy (through the ribs), and also using robot-assisted surgery (through tiny keyholes in the chest). Full open heart surgery is usually reserved for very large<unk> s and/or specific situations that make thoracotomy difficult. By far, Stanford University has done more unroofing surgeries than any other hospital in the world, with over 200 unroofings completed since starting a decade ago. In 2019, University of Chicago surgeon Dr. Husam Balkhy emerged as a provider of robotic-assisted unroofing surgery, with some patients being possible candidates for this route. If done properly, unroofing removes the entire band of muscle affecting the artery, restoring more blood flow. Stanford University Medical Center's 2016 study by Pargaonkar et al. showed that unroofing surgery “significantly improves anginal symptoms” and improves “all five dimensions of the SAQ” i.e. Seattle Angina Questionnaire. Some residual symptoms caused by complications from a lifetime of living with a<unk>  may continue after unroofing surgery such as endothelial dysfunction, vasospasm, plaque, narrowed artery. However, these often improve slowly over a year or more once the<unk>  is gone. A few cases have occurred in various hospitals in which patients have not been completely unroofed, leaving segments of the<unk> , resulting in lingering symptoms. A critical point is that the endothelial dysfunction and vasospasms caused by<unk> s cannot start to heal until unroofing surgery is done, because the<unk>  continues to squeeze on the artery, damaging the artery lining. Bypass surgery is not the first line treatment for<unk> s for two main reasons: # Competitive flow problem - blood can flow the wrong way i.e. continue to flow down the original artery instead of the new artery that has been grafted on. # Jailed septal arteries still jailed - a jailed artery is a septal artery (a branch off the coronary artery) that lies inside the<unk>  and is thus also compressed with each heartbeat. Septal arteries are critical as they carry blood into the heart septum. Bypass surgery alone does not remedy jailed septal arteries, which still do not get blood flow. Notably, many<unk>  patients have had bypass surgery only to later need unroofing surgery after the bypass proved unsuccessful. However, papers by Ekeke et al., 2015 and others have shown bypass surgery is helpful as an addition to supplement unroofing surgery, but only when there is significant plaque just before (proximal to) the<unk>  or anatomic anomalies increase the risk of recurrence of such plaque. A 2013 Russian study by Bockeria et al. concludes that this competitive flow problem is much more likely to occur if the LIMA artery is used for the graft rather than the SVG, so the SVG is recommended. Stents are never indicated as a treatment for<unk> s because trials have shown they are prone to breaking when the artery is squeezed each heartbeat. Unroofing surgery has been performed in the United States, Belgium, Spain, Italy, England, China, Russia, United Arab Emirates among other countries. Hospitals that have performed unroofing surgery include: * Stanford University Medical Center - surgeon Dr. Jack Boyd; team leader Dr. Ingela Schnittger * University of Chicago Medical Center - surgeon Dr. Husam Balkhy * Mayo Clinic, Rochester, Minnesota * Cleveland Clinic * Cleveland Clinic Abu Dhabi - surgeon Dr. Johannes Bonatti (currently in Austria) * Texas Heart Institute * Kaiser Permanente, Santa Clara, CA - Dr. David Scoville * Baylor Scott and White Hospital, Texas - surgeon Dr. Jeffrey Wu * Spectrum Health Butterworth Hospital, Michigan – Dr. Marzia Leacche * Hospital de las Cruces, Barakaldo, Basque Country, Spain - Dr. Crespo and Dr. Aramendi * Istanbul University Hospital - Dr. Ihsan Bakir In many other countries, including a number of highly developed countries such as the UK, Australia, New Zealand, Ireland, Sweden, and Singapore, unroofing surgery for<unk> s remains unavailable, and in some, the condition remains unrecognized as a medical problem.
Myocardial bridge
Myocardial disarray
Hypertrophic scar
Contraction band necrosis
Buddy wrapping
Infibulation
Blunt dissection
Dural tear