Therapeutic management of hypertrophic obstructive cardiomyopathy: alcohol septal ablation or surgical myomectomy?

Hypertrophic cardiomyopathy (HCM) is characterized as left ventricular hypertrophy unexplained by abnormal loading conditions. Approximately 30% of patients with HCM will develop left ventricular outflow obstruction under resting conditions. In the 5-10% of patients with drug-refractory symptoms, surgical septal myectomy has been shown to reduce outflow obstruction and relieve symptoms; however, some patients may be at increased risk for surgery. Since 1994, when alcohol septal ablation was introduced, an increasing number of patients have opted for the percutaneous approach, which aims to mimic the anatomic and hemodynamic effects of surgical septal myectomy. The less-invasive version of septal reduction therapy comes at a price: a larger number of pacemaker implantations and, sometimes, depending on the individual's coronary anatomy, a higher residual gradient. Despite these shortcomings and the absence of randomized trials, alcohol septal ablation has established itself as a viable option for patients with obstructive HCM.