ALCOHOL SEPTAL ABLATION VS. SEPTAL MYECTOMY FOR HOCM: WHEN TO DO WHICH


Michael A. Fifer, M.D., Massachusetts General Hospital, Boston, MA, USA

Alcohol septal ablation (ASA) was introduced in 1995 as an alternative to surgical septalmyectomy for patients with hypertrophic obstructive cardiomyopathy and symptoms refractory to optimal medical therapy. (No randomized comparative trials of ASA vs. myectomy have been done or planned. Data from nonrandomized comparative studies and metanalyses have shown similar benefit of and mortality for the 2 procedures (J Am CollCardiol 2010;55:823).

Advantages of ASA include less morbidity, faster recovery, and lower cost. Advantages of septalmyectomy include more immediate relief of left ventricular outflow tract (LVOT) obstruction, longer duration of experience with the procedure, and a lower incidence of requirement for permanent pacing. For an individual patient, factors favoring ASA are older age, comorbidity, right bundle branch block (since myectomy usually causes left bundle branch block), and presence of a pacemaker or implanted cardioverter defibrillator. Factors favoring septalmyectomy are younger age, marked septal hypertrophy, need for immediate relief of LVOT obstruction, and left bundle branch block (since ASA usually causes right bundle branch block). For many patients, both procedures are reasonable, allowing patients to choose between them after a balanced discussion of benefits and risks (Circulation 2007;116:207).