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

Historical Context

Almost from its initial recognition in the early 1960s, dynamic obstruction to LV outflow was regarded as a prominent mechanism responsible for limiting symptoms in HCM,[1–3,5] and surgical septal myectomy initially emerged as the primary strategy for relieving this mechanical impedance to LV ejection.[5] Later, in the early 1990s, dual-chamber pacing was introduced as an alternative treatment to reduce gradient and functional limitation, but the apparent symptom benefit in some patients was ultimately explained largely as a placebo effect.[6] More recently, over the last decade, the interventional cardiology community has aggressively promoted percutaneous alcohol septal ablation (ASA) as a superior and easier treatment option to replace surgical myectomy.[7–11]

Despite competition from more novel strategies and periods of scepticism, the septal myectomy operation (initially known as the Morrow procedure)[12] has nevertheless survived over the past 50 years, and even flourished in some centres, particularly in the USA and Canada.[13–22] Indeed, by virtue of consensus panel recommendations from both North America and Europe, and the practice of those clinicians with long-standing expertise in treating patients with HCM, surgery continues to be the preferred treatment option (i.e. 'the gold standard' for most drug-refractory and severely symptomatic HCM patients with outflow obstruction).[1]

However, over the last 10 years, we have witnessed an unbridled enthusiasm for ASA in some quarters, sometimes resembling evangelical zeal. Indeed, dialogue (largely from European investigators) has advanced ASA with premature and strong proclamations that the surgical myectomy: '… has been usurped and no longer can claim a significant role in the management of obstructive HCM', and even represents 'an impediment to development of ASA' that must be 'marginalized or abandoned, "and that ASA is already established as the 'new gold standard for the 21st Century' … " because it avoids all the problems associated with open heart surgery'.[3,23–26]

Even though myectomy and ASA have the same indications—i.e. marked outflow obstruction and unrelenting heart failure disability (New York Heart Association classes III/IV),[1] the promotion of ASA has sometimes seemed excessive. This is evidenced by the observation that the number of these procedures performed in cardiac catheterization laboratories over the last 10 years throughout the world (now far exceeding 5000),[3,4] in patients of all ages and even young children,[27,28] has already rapidly exceeded numerically all septal myectomies performed over the last 50 years.[3] Paradoxically, this heightened visibility afforded by the introduction of ASA for the treatment of obstructive HCM has also been accompanied by a steady increase in the number of myectomies performed at major US centres (e.g. now 190/year at Mayo Clinic).[18] Therefore, to a certain extent, different and distinctive management strategies have evolved in the USA and Europe for this important subgroup of HCM patients, and we will argue—the unfortunate demise of myectomy in much of Europe.

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