Surgical Myectomy Remains the Primary Treatment Option for Severely Symptomatic Patients With Obstructive Hypertrophic Cardiomyopathy

Abstract

The evolving alcohol septal ablation versus surgical myectomy controversy represents a crossroad in the management of obstructive hypertrophic cardiomyopathy (HCM). Indeed, in this now polarized debate within the cardiovascular community, between the traditional and established (ie, surgery) and the new and percutaneous (ie, ablation), much is at stake for the HCM patient population. Furthermore, this issue has become increasingly important given the visibility recently afforded the pathophysiological significance and frequency of left ventricular (LV) outflow gradients in this disease.1,2 Response by Fifer p 206 In the course of this discussion, I will vigorously defend surgery as the primary treatment of choice when outflow obstruction (gradient ≥50 mm Hg at rest or with physiological exercise) produces heart failure symptoms refractory to maximal medical management (New York Heart Association functional classes III and IV).3,4 To this purpose, I will rely on the 50-year experience and substantial body of evidence available in HCM, as well as my own personal extensive association with and work in this disease spanning >30 years and several hundred publications—neither as a surgeon or interventional cardiologist nor with any particular allegiance to either discipline. The message expressed herein is prosurgery, but it is by no means antiablation, for this treatment modality has proved useful (although with a selective role) in the management of HCM. ### Historical Context When surgical septal myectomy (Table 1) was initially introduced in the early 1960s at several North American and European centers, it was regarded as revolutionary and has subsequently stood the test of time. The classic myectomy (Morrow operation)5 relieves obstruction by resection of a relatively small amount of muscle (2 to 5g) from the proximal ventricular septum, thereby widening the outflow tract and abolishing flow drag (or Venturi) forces that promote systolic contact between mitral valve and hypertrophied septum, resulting in immediate …