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Fast Five Quiz: Obstructive HCM Management
Learn more about beta-blockers for obstructive HCM.
Guidelines from the US, Canada, and Europe recommend alcohol septal ablation over invasive surgery for patients with advanced age and comorbidities, due to its less invasive nature and shorter recovery time. However, alcohol septal ablation has been associated with higher risk for complete heart block requiring permanent pacing and might result in less uniform reduction in LVOT gradient, similar to myectomy. It should not be used in pediatric or younger patients or those with cardiac abnormalities that would require surgery.
Learn more about alcohol septal ablation for obstructive HCM.
Transaortic septal myectomy is the preferred treatment for patients with obstructive HCM who have severe, drug-refractory symptoms, according to a state-of-the-art review from the Journal of American College of Cardiology. Similarly, Canadian guidelines note that surgical myectomy is 'usually' the most effective therapy for obstruction and has a low risk for adverse outcomes, although contraindications to its use do exist. The AHA also notes that transaortic septal myectomy adds little risk to other cardiac procedures and that the relief in left ventricular outflow tract obstruction can minimize postoperative hemodynamic instability.
Although dual chamber pacing and mitral valve replacement are effective treatments and can be used for management in some cases, transaortic septal myectomy is generally the preferred option.
Learn more about surgical myectomy for obstructive HCM.
Surgical myectomy is encouraged to be performed in high-volume HCM centers because in-hospital mortality for surgical myectomy is inversely correlated with surgical volume. Specifically, one recent review found that high-volume hospitals had an in-hospital mortality rate for surgical myectomy of 2.4% compared with 3.9% for medium volume and 5.7% for low volume centers. Another recent review notes that mortality rate for surgical myectomy has decreased 'strikingly' from the highs of up to 8% from 30 years ago but also acknowledges the need for more experienced surgeons in the US and Europe to increase its accessibility.
Learn more about surgical outcomes for obstructive HCM.
A recent review of HCM published by the American Journal of Cardiology lists history of sustained or repetitive ventricular tachycardia, unexplained syncope, massive left ventricular hypertrophy, or extensive late gadolinium enhancement or a family history of this complication as indications for implantable cardioverter-defibrillators. Similarly, the AHA/ACC joint guidelines specifically recommend an implantable cardioverter-defibrillator for patients with any prior history of sudden cardiac arrest, ventricular fibrillation, or sustained ventricular tachycardia. It should also be considered in shared decision-making with a 5-year risk estimate if a patient has an ejection fraction < 50%, apical aneurysm, unexplained syncope, massive left ventricular hypertrophy, or a family history of sudden cardiac death.
Though mild left ventricular hypertrophy and minimal late gadolinium enhancement on cardiac MRI can cause cardiovascular events in patients with obstructive HCM, they are typically not sole indicators for implanting a cardioverter-defibrillator. Asymptomatic status with normal exercise capacity is not an indicator as well.
Learn more about implantable cardioverter defibrillators for obstructive HCM.
This article was created using several editorial tools, including generative AI models, as part of the process. Human review and editing of this content were performed prior to publication. Lead image: Science Source
