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Surgical Septal Myectomy Versus Alcohol Septal Ablation: Assessing the Status of the Controversy in 2014

In hypertrophic cardiomyopathy (HCM), left ventricular (LV) outflow tract obstruction, caused by mitral valve systolic anterior motion (SAM) with elevated intracavitary LV pressures, can produce disabling symptoms of heart failure and excess cardiovascular mortality.1–7 Outflow gradients are common in HCM, present in 70% of patients at rest or with physiological exercise4 (Figure 1). Fifty years ago, early HCM investigators recognized the importance of obliterating LV outflow obstruction (and mitral regurgitation) and restoring normal hemodynamics, initially with the septal myectomy operation advanced by Dr Andrew Morrow at the National Institutes of Health.6,7 However, HCM has not been immune to controversy, and through the years, several debates have focused on the significance of dynamic outflow obstruction and its treatment.7 The most recent of these conversations concerns the most effective strategy for reducing gradient and symptoms, triggered by the introduction of catheter-based percutaneous alcohol septal ablation (ASA) as an alternative to myectomy.8–19



Figure 1. 
Treatment algorithm for hypertrophic cardiomyopathy (HCM) patients with heart failure symptoms of exertional dyspnea with or without chest pain. LVOT indicates left ventricular outflow tract; and NYHA, New York Heart Association.



The nonsurgical technique, introduced by Professor Ulrich Sigwart at the Royal Brompton Hospital in 1994,8 involves injection of 1 to 4 mL of 96% ethanol into the first septal perforator branch of the left anterior descending coronary artery to produce a basal septal myocardial infarction and ultimately remodeling of the LV outflow tract. ASA avoids the recovery time with loss of work, residual discomfort, and anxiety associated with surgery. It was soon enthusiastically embraced and heavily promoted by many clinicians and interventional cardiologists, initially in Europe, thereby expanding the treatment armamentarium of HCM and triggering a polarized and sometimes contentious debate within the cardiovascular community.

Indeed, many related …