Benefits of Surgery in Obstructive Hypertrophic Cardiomyopathy: Bring Septal Myectomy Back for European Patients

Bring Septal Myectomy Back for European Patients

Barry J. Maron; Magdi Yacoub; Joseph A. Dearani

Disclosures

Eur Heart J. 2011;32(9):1055-1058. 

In This Article

Abstract and Introduction

Abstract

Hypertrophic cardiomyopathy (HCM), a heterogeneous genetic heart disease with global distribution, is an important cause of heart failure disability at any age. For 50 years, surgical septal myectomy has been the preferred and primary treatment strategy for most HCM patients with progressive, drug refractory functional limitation due to left ventricular (LV) outflow tract obstruction. With very low surgical mortality at experienced centres, septal myectomy reliably abolishes impedance to LV outflow and heart failure-related symptoms, restores quality of life, and importantly is associated with long-term survival similar to that in the general population. Nevertheless, alternatives to surgical management are necessary for selected HCM patients. For example, after a brief flirtation with dual-chamber pacing 20 years ago, percutaneous alcohol septal ablation has garnered a large measure of enthusiasm and a dedicated following in the interventional cardiology community, achieving benefits for patients, paradoxically, by virtue of producing a transmural myocardial infarct. However, an unintended consequence has been the virtual obliteration of the surgical option for HCM patients in Europe, where several robust myectomy programmes once existed. Therefore, clear differences are now evident internationally regarding management strategies for symptomatic obstructive HCM. The surgical option is now unavailable to many patients based solely on geography, including some who would likely benefit more substantially from surgical myectomy than from catheter-based alcohol ablation. It is our aspiration that this discussion will generate reconsideration and resurgence of interest in surgical septal myectomy as a treatment option for severely symptomatic obstructive HCM patients within Europe.

Introduction

Severely symptomatic drug-refractory patients with left ventricular (LV) outflow tract obstruction represent an important and highly visible (although relatively small) subset within the broad disease spectrum of hypertrophic cardiomyopathy (HCM).[1,2] Alleviation of outflow gradient and associated disabling symptoms requires invasive intervention, but selection of the most appropriate management strategy—surgery vs. catheter-based therapy—has created controversy and even contentious debate.[3,4] As a result, divergent practice patterns have emerged in different countries and parts of the world.

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