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

Myectomy in Europe

Following the introduction of ASA by Sigwart,[65] the time-honoured myectomy operation rapidly disappeared from most European centres, including countries formerly with rich surgical traditions and experience such as Germany[30,38] and Switzerland[31] (Figure 1). An exception would appear to be the strong surgical programme which remains at the aforementioned Thoraxcenter in Rotterdam,[32,47,58] although recently there has also been a re-emergence of surgical myectomy in Italy (Florence, Bergamo, and Milan) and London. However, we could not find evidence of a robust myectomy programme in the other 45 European countries, with a combined population 2.5-fold that of the USA substantiating that myectomy has been greatly reduced in Europe, both in terms of surgical centres and the number of operated patients, but associated with proliferation of cardiac centres performing alcohol ablation. Of note, however, Egypt (which is an ESC member) has developed the myectomy option.[19]

Figure 1.

Map of Europe with current surgical myectomy centres denoted by red symbols.

The current status of surgical myectomy in much of Europe deviates from ESC recommendations for the management of HCM.[1] This mismatch, driven by the strong preference for ASA throughout much of Europe over the last decade, has also impaired the future of myectomy, as few experienced and qualified myectomy surgeons remain. This dilemma in patient selection is largely determined by the 'gatekeeper effect'.[3] When cardiologists directing patient referrals abandon the myectomy option in favour of ASA, an unintended consequence is the loss of surgical expertise with myectomy, which in turn has essentially resulted in the loss of a generation of European surgeons experienced with this operation. Ultimately, this unfortunate scenario could establish ASA as the only primary therapeutic option in Europe, with obstructive HCM eventually regarded as a non-operative disease, and myectomy relegated to a last resort procedure for only those patients who fail ASA.[66]

In the USA, after the ill-advised closure of the National Institutes of Health cardiac surgery programme 20 years ago, this issue has been addressed directly by the active promotion of comprehensive 'HCM Centers'[67] in which an integrated team approach provides all diagnostic and treatment modalities essential for the optimal management of HCM, including myectomy as well as ASA. In addition to the prominent and long-standing North American surgical centres: Mayo Clinic, Cleveland Clinic, and Toronto General, myectomy programmes have more recently emerged at Tufts Medical Center (Boston, MA, USA), as well as Stanford, Michigan, Johns Hopkins, Northwestern, and Columbia (Roosevelt-St Lukes Hospital Center, New York, NY, USA). Several other comprehensive centres are in the developmental process.

In conclusion, over the last decade, the growing influence of catheter-based ASA and the virtual extinction of surgical myectomy in many European countries have had a far reaching impact by fundamentally altering the equilibrium of HCM management. We do not believe that this development is particularly advantageous for the management of all HCM patients. Surgical myectomy may well be the better choice for many severely symptomatic patients with obstructive HCM, some of whom may even be unaware that a long-standing alternative to the newer ASA exists. Indeed, we believe that it is a basic principle, particularly with relatively uncommon diseases such as HCM, for patients to be fully informed of (and have potential access to) all relevant treatment strategies that may affect their clinical course,[68] allowing them the opportunity to weigh the advantages and disadvantages of each option.

Although many HCM patients in Europe and elsewhere have benefited from ASA over the last 15 years, it is our aspiration that the arguments presented here in support of surgical septal myectomy will represent an impetus in Europe for the resurgence and rejuvenation of this time-honoured strategy. We also hope that our arguments will be viewed in the context of patient opportunity and benefit, as intended. Indeed, we can only agree wholeheartedly with Dr Sigwart, who conceived the competing catheter-based technique, and believes that alcohol ablation: '… was never devised to replace surgery for symptomatic obstructive HCM'.[4]

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