Review of Contemporary Invasive Treatment Approaches and Critical Appraisal of Guidelines on Hypertrophic Obstructive Cardiomyopathy: State-of-the-Art Review

Abstract

Background: Hypertrophic obstructive cardiomyopathy (HOCM) is a heterogeneous disease with different clinical presentations, albeit producing similar dismal long-term outcomes if left untreated. Several approaches are available for the treatment of HOCM; e.g., alcohol septal ablation (ASA) and surgical myectomy (SM). The objectives of the current review were to (1) discuss the place of the standard invasive treatment modalities (ASA and SM) for HOCM; (2) summarize and compare novel techniques for the management of HOCM; (3) analyze current guidelines addressing HOCM management; and (4) offer suggestions for the treatment of complex HOCM presentations. Methods: We searched the literature and attempted to gather the most relevant and impactful available evidence on ASA, SM, and other invasive means of treatment of HOCM. The literature search yielded thousands of results, and 103 significant publications were ultimately included. Results: We critically analyzed available guidelines and provided context in the setting of patient selection for standard and novel treatment modalities. This review offers the most comprehensive analysis to-date of available invasive treatments for HOCM. These include the standard treatments, SM and ASA, as well as novel treatments such as dual-chamber pacing and radiofrequency catheter ablation. We also account for complex pathoanatomic presentations and current guidelines to offer suggestions for tailored care of patients with HOCM. Finally, we consider promising future therapies for HOCM. Conclusions: HOCM is a heterogeneous disease associated with poor outcomes if left untreated. Several strategies for treatment of HOCM are available but patient selection for the procedure is crucial.

A systematic review of present and future pharmaco‐structural therapies for hypertrophic cardiomyopathy

“…Comparing ASA to SM, several meta‐analyses demonstrated ASA having higher rates of permanent pacemaker (PPM) implantation and reintervention. In contrast, SM is associated with greater rates of peri‐procedural mortality and stroke 25–34 …”

“…Furthermore, the inability to address concomitant anatomic abnormalities of the mitral valve or LVOT and higher PPM requirements make this a less favorable choice. Nonetheless, several advantages are present, including faster recovery time and avoidance of an open sternal incision 5,7,10,25,30,39,49 …”

“…In contrast, SM is associated with greater rates of peri-procedural mortality and stroke. [25][26][27][28][29][30][31][32][33][34] The first septal myectomy was performed in 1958. 35 Surgery involves resection of the septum through an aortic incision, which results in the widening of left ventricular outflow tract (LVOT), reduction in systolic anterior motion, mitral regurgitation and LVOTO.…”

“…Nonetheless, several advantages are present, including faster recovery time and avoidance of an open sternal incision. 5,7,10,25,30,39,49 It is important to note that outcomes for these invasive procedures are related to procedural volumes. A nationwide inpatient database included 6386 patients who underwent SM and 4862 who underwent ASA.…”

Trends of hypertrophic cardiomyopathy-related mortality in United States young adults: a nationwide 20-year analysis

“…29 Secondly, the advances in the surgical septal myectomy technique (or alcohol ablation) and heart transplantation have further contributed to reducing the HCM-related mortality rate in younger patients. [30][31][32] Thirdly, young adults present less frequent HCM-related complications, such as heart failure and atrial fibrillation, as well as a lower competing risk of noncardiac death. 29…”