Surgery Versus Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy: The Controversy

Hypertrophic cardiomyopathy is a common genetic illness affecting approximately one in 500 of the general population. The disease may occur spontaneously or be inherited in an autosomal dominant pattern.1 Initially, it was felt that most patients with this illness had severe symptoms of heart failure, angina and syncope and were at high risk for sudden death. However, population studies have revealed that many patients are asymptomatic and do not have the high risk of sudden death originally found in symptomatic patients referred to tertiary medical centers.

Roughly one-third of those with hypertrophic cardiomyopathy have obstructed left ventricular outflow, and the severity of the obstruction is measured by the left ventricular outflow tract gradient. Therapies that reduce the pressure gradient have been shown to improve symptoms and outcomes of patients with hypertrophic obstructive cardiomyopathy (HOCM).2 Many live with minimal symptoms while taking drugs such as beta blockers or calcium channel blockers. Dual-chamber cardiac pacemakers, while originally thought to effectively reduce the left ventricular outflow tract gradient, have in reality had very limited applicability in treating HOCM.1 For severely symptomatic patients, cardiac surgery has been a long-standing therapy. Recently, however, alcohol septa! ablation (ASA) has emerged as an alternative to surgery.3