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CONSENSUS DOCUMENT

American College of Cardiology/European Society of Cardiology Clinical Expert Consensus Document on Hypertrophic Cardiomyopathy

a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines

Barry J. Maron, MD, FACC, FESC, Co-Chair, Writing Committee Member, William J. McKenna, MD, FACC, FESC, Co-Chair, Writing Committee Member^*, Gordon K. Danielson, MD, FACC, Writing Committee Member, Lukas J. Kappenberger, MD, FACC, FESC, Writing Committee Member^*, Horst J. Kuhn, MD, FESC, Writing Committee Member^*, Christine E. Seidman, MD, Writing Committee Member, Pravin M. Shah, MD, MACC, Writing Committee Member, William H. Spencer, III, MD, FACC, Writing Committee Member, Paolo Spirito, MD, FACC, FESC, Writing Committee Member^*, Folkert J. Ten Cate, MD, PhD, FACC, FESC, Writing Committee Member^*, E. Douglas Wigle, MD, FACC, Writing Committee Member, Robert A. Vogel, MD, FACC, Chair, Task Force Member, Jonathan Abrams, MD, FACC, Task Force Member, Eric R. Bates, MD, FACC, Task Force Member, Bruce R. Brodie, MD, FACC, Task Force Member^**, Peter G. Danias, MD, PhD, FACC, Task Force Member^**, Gabriel Gregoratos, MD, FACC, Task Force Member, Mark A. Hlatky, MD, FACC, Task Force Member, Judith S. Hochman, MD, FACC, Task Force Member, Sanjiv Kaul, MBBS, FACC, Task Force Member, Robert C. Lichtenberg, MD, FACC, Task Force Member, Jonathan R. Lindner, MD, FACC, Task Force Member, Robert A. O’rourke, MD, FACC, Task Force Member, Gerald M. Pohost, MD, FACC, Task Force Member, Richard S. Schofield, MD, FACC, Task Force Member, Cynthia M. Tracy, MD, FACC, Task Force Member^**, William L. Winters, Jr, MD, MACC, Task Force Member^**, Werner W. Klein, MD, FACC, FESC, Chair, Task Force Member, Silvia G. Priori, MD, PhD, FESC, Co-Chair, Task Force Member, Angeles Alonso-Garcia, MD, FACC, FESC, Task Force Member, Carina Blomström-Lundqvist, MD, PhD, FESC, Task Force Member, Guy De Backer, MD, PhD, FACC, FESC, Task Force Member, Jaap Deckers, MD, FESC, Task Force Member, Markus Flather, MD, FESC, Task Force Member, Jaromir Hradec, MD, FESC, Task Force Member, Ali Oto, MD, FACC, FESC, Task Force Member, Alexander Parkhomenko, MD, FESC, Task Force Member, Sigmund Silber, MD, PhD, FESC, Task Force Member and Adam Torbicki, MD, FESC, Task Force Member

	Table of contents

Top Table of contents Preamble Introduction General considerations and... Nomenclature, definitions, and... Obstruction to LV outflow Genetics and molecular diagnosis General considerations for... Symptoms and pharmacological... Treatment options for drug... Surgery Additional approaches to relieve... Sudden cardiac death Atrial fibrillation References

Introduction......1688

General Considerations and Perspectives......1688

Nomenclature, Definitions, and Clinical Diagnosis......1689

Obstruction to LV Outflow......1689

Genetics and Molecular Diagnosis......1690

General Considerations for Natural History and Clinical Course......1692

Symptoms and Pharmacological Management Strategies......1693

Treatment Options for Drug-Refractory Patients......1697

Additional Approaches to Relieve Outflow Obstruction and Symptoms......1698

Sudden Cardiac Death......1702

Atrial Fibrillation......1706

	Preamble

Top Table of contents Preamble Introduction General considerations and... Nomenclature, definitions, and... Obstruction to LV outflow Genetics and molecular diagnosis General considerations for... Symptoms and pharmacological... Treatment options for drug... Surgery Additional approaches to relieve... Sudden cardiac death Atrial fibrillation References

 
This document has been developed as a Clinical Expert Consensus Document (CECD), combining the resources of the American College of Cardiology Foundation (ACCF) and the European Society of Cardiology (ESC). It is intended to provide a perspective on the current state of management of patients with hypertrophic cardiomyopathy. Clinical Expert Consensus Documents are intended to inform practitioners, payers, and other interested parties of the opinion of the ACCF and the ESC concerning evolving areas of clinical practice and/or technologies that are widely available or new to the practice community. Topics chosen for coverage by expert consensus documents are so designed because the evidence base, the experience with technology, and/or the clinical practice are not considered sufficiently well developed to be evaluated by the formal American College of Cardiology/American Heart Association (ACC/AHA) Practice Guidelines process. Often the topic is the subject of considerable ongoing investigation. Thus, the reader should view the CECD as the best attempt of the ACC and the ESC to inform and guide clinical practice in areas where rigorous evidence may not yet be available or the evidence to date is not widely accepted. When feasible, CECDs include indications or contraindications. Some topics covered by CECDs will be addressed subsequently by the ACC/AHA Practice Guidelines Committee.

The Task Force on Clinical Expert Consensus Documents makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the writing panel. Specifically, all members of the writing panel are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest to inform the writing effort. These statements are reviewed by the parent task force, reported orally to all members of the writing panel at the first meeting, and updated as changes occur.

Robert A. Vogel, MD, FACCChair, ACCF Task Force on Clinical Expert Consensus Documents Werner W. Klein, MD, FACC, FESC Chair, ESC Committee for Practice Guidelines

	Introduction

Top Table of contents Preamble Introduction General considerations and... Nomenclature, definitions, and... Obstruction to LV outflow Genetics and molecular diagnosis General considerations for... Symptoms and pharmacological... Treatment options for drug... Surgery Additional approaches to relieve... Sudden cardiac death Atrial fibrillation References

 
Organization of committee and evidence review.   The Writing Committee consisted of acknowledged experts in hypertrophic cardiomyopathy (HCM) representing the American College of Cardiology Foundation and the European Society of Cardiology. Both the academic and private practice sectors were represented. The document was reviewed by 2 official reviewers nominated by the ACCF, 3 official reviewers nominated by the ESC, 12 members of the ACCF Clinical Electrophysiology Committee, and 4 additional content reviewers nominated by the Writing Committee. The document was approved for publication by the ACCF Board of Trustees in August 2003 and the Board of ESC in July 2003. This document will be considered current until the task force on clinical expert consensus documents revises or withdraws it from distribution. In addition to the references cited as part of this document, a comprehensive bibliography including relevant, supplementary references is available on the ACCF and ESC websites.

Purpose of this expert consensus document.   Hypertrophic cardiomyopathy is a complex and relatively common genetic cardiac disorder (about 1:500 in the general adult population) (1) that has been the subject of intense scrutiny and investigation for over 40 years (2–15). hypertrophic cardiomyopathy affects men and women equally and occurs in many races and countries, although it appears to be under-diagnosed in women, minorities, and under-served populations (16–20).

Hypertrophic cardiomyopathy is a particularly common cause of sudden cardiac death (scd) in young people (including trained athletes) (21–29) and may cause death and disability in patients of all ages, although it is also frequently compatible with normal longevity (30–35). because of its heterogeneous clinical course and expression (7,36–42), hcm frequently presents uncertainty and represents a management dilemma to cardiovascular specialists and other practitioners, particularly those infrequently engaged in the evaluation of patients with this disease.

Furthermore, with the recent introduction of novel treatment strategies targeting subgroups of patients with hcm (7,43–49), controversy is predictable, and difficult questions periodically arise. consequently, it is now particularly timely to clarify and place into perspective those clinical issues relevant to the rapidly evolving management for hcm.

	General considerations and perspectives

Top Table of contents Preamble Introduction General considerations and... Nomenclature, definitions, and... Obstruction to LV outflow Genetics and molecular diagnosis General considerations for... Symptoms and pharmacological... Treatment options for drug... Surgery Additional approaches to relieve... Sudden cardiac death Atrial fibrillation References

 
This clinical scientific statement represents the consensus of a panel of experts appointed by the ACC and ESC. The writing group is comprised of cardiovascular specialists and molecular biologists, each having extensive experience with HCM. The panel focused largely on the management of this complex disease and derived prudent, practical, and contemporary treatment strategies for the many subgroups of patients comprising the broad HCM disease spectrum. Because of the relatively low prevalence of HCM in general cardiologic practice (50), its diverse presentation, and mechanisms of death and disability and skewed patterns of patient referral (7,11,13,36–38,42,51–59), the level of evidence governing management decisions for drugs or devices has often been derived from non-randomized and retrospective investigations. Large-scale controlled and randomized study designs, such as those that have provided important answers regarding the management of coronary artery disease (CAD) and congestive heart failure (60–62), have generally not been available in HCM as a result of these factors. Therefore, treatment strategies have necessarily evolved based on available data that have frequently been observational in design, sometimes obtained in relatively small patient groups, or derived from the accumulated clinical experience of individual investigators, and reasonable inferences drawn from other cardiac diseases. Consequently, the construction of strict clinical algorithms designed to assess prognosis and dictate treatment decisions for all patients has been challenging and has not yet achieved general agreement. In some clinical situations, management decisions and strategies unavoidably must be individualized to the particular patient.

Understanding of the molecular basis, clinical course, and treatment of HCM has increased substantially in the last decade. In particular, there has been a growing awareness of the clinical and molecular heterogeneity characteristic of this disorder and the many patient subgroups that inevitably influence considerations for treatment. Some of these management strategies are novel and evolving, and this document cannot, in all instances, convey definitive assessments of their role in the treatment armamentarium. Also, for some uncommon subsets within the broad disease spectrum, there are little data currently available to definitively guide therapy. With these considerations in mind, the panel has aspired to create a document that is not only current and pertinent but also has the potential to remain relevant for many years.

	Nomenclature, definitions, and clinical diagnosis

Top Table of contents Preamble Introduction General considerations and... Nomenclature, definitions, and... Obstruction to LV outflow Genetics and molecular diagnosis General considerations for... Symptoms and pharmacological... Treatment options for drug... Surgery Additional approaches to relieve... Sudden cardiac death Atrial fibrillation References

 
The clinical diagnosis of HCM is established most easily and reliably with two-dimensional echocardiography by demonstrating left ventricular hypertrophy (LVH) (typically asymmetric in distribution, and showing virtually any diffuse or segmental pattern of left ventricular [LV] wall thickening) (36). Left ventricular wall thickening is associated with a nondilated and hyperdynamic chamber (often with systolic cavity obliteration) in the absence of another cardiac or systemic disease (e.g., hypertension or aortic stenosis) capable of producing the magnitude of hypertrophy evident, and independent of whether or not LV outflow obstruction is present (1,5,7,36). Although the usual clinical diagnostic criteria for HCM is a maximal LV wall thickness greater than or equal to 15 mm, genotype-phenotype correlations have shown that virtually any wall thickness (including those within normal range) are compatible with the presence of a HCM mutant gene (6,17,19,63–65). Mildly increased LV wall thicknesses of 13 to 14 mm potentially due to HCM should be distinguished from certain extreme expressions of the physiologically-based athlete's heart (66–68). The advent of contemporary magnetic resonance imaging that provides high-resolution tomographic images of the entire LV may represent an additional diagnostic modality (69) particularly in the presence of technically suboptimal echocardiographic studies or when segmental hypertrophy is confined to unusual locations within the LV wall.

Since the modern description by Teare in 1958 (12), HCM has been known by a confusing array of names that largely reflect its clinical heterogeneity, relatively uncommon occurrence in cardiologic practice, and the skewed experience of early investigators. This problem in nomenclature has been an obstacle to general recognition of the disease within the medical and non-medical community. Hypertrophic cardiomyopathy (or HCM) is now widely accepted as the preferred term (7) because it describes the overall disease spectrum without introducing misleading inferences that LV outflow tract obstruction is an invariable feature of the disease, such as is the case with hypertrophic obstructive cardiomyopathy (70), muscular subaortic stenosis (71), or idiopathic hypertrophic subaortic stenosis (72). Indeed, most patients with HCM do not demonstrate outflow obstruction under resting (basal) conditions, although many may develop dynamic subaortic gradients of varying magnitude with provocative maneuvers or agents (7,13,41,72–77). Of note, even though the absence of obstruction (at rest) is common, both in patients with and without symptoms, most treatment modalities have targeted those symptomatic HCM patients with outflow obstruction (41,43–49,78–108).

	Obstruction to LV outflow

Top Table of contents Preamble Introduction General considerations and... Nomenclature, definitions, and... Obstruction to LV outflow Genetics and molecular diagnosis General considerations for... Symptoms and pharmacological... Treatment options for drug... Surgery Additional approaches to relieve... Sudden cardiac death Atrial fibrillation References

 
It is of clinical importance to distinguish between the obstructive or nonobstructive forms of HCM, based on the presence or absence of a LV outflow gradient under resting and/or provocable conditions (5,7,11,13,41,109,110). Indeed, in most patients, management strategies have traditionally been tailored to the hemodynamic state. Outflow gradients are responsible for a loud apical systolic ejection murmur associated with a constellation of unique clinical signs (14,72,111), hypertrophy of the basal portion of ventricular septum and small outflow tract, and an enlarged and elongated mitral valve in many patients (39,112–114). Obstruction may either be subaortic (13,71,72) or mid-cavity (13,115) in location. Subaortic obstruction is caused by systolic anterior motion (SAM) of the mitral valve leaflets and mid-systolic contact with the ventricular septum (13,71,113,116–119). This mechanical impedance to outflow occurs in the presence of high velocity ejection in which a variable proportion of the forward blood flow may be ejected early in systole (120,121). Systolic anterior motion is probably attributable to a drag effect (117,122) or possibly a Venturi phenomenon (13,118) and is responsible not only for subaortic obstruction, but also the concomitant mitral regurgitation (usually mild-to-moderate in degree) due to incomplete leaflet apposition, which is typically directed posteriorly into the left atrium (111,123). When the mitral regurgitation jet is directed centrally or anteriorly into the left atrium, or if multiple jets are present, independent abnormalities intrinsic to the mitral valve should be suspected (e.g., myxomatous degeneration, mitral leaflet fibrosis, or anomalous papillary muscle insertion) (13,91,115,124). Occasionally (perhaps in 5% of cases), gradients and impeded outflow are caused predominately by muscular apposition in the mid-cavity region—usually in the absence of mitral-septal contact—involving anomalous direct insertion of anterolateral papillary muscle into the anterior mitral leaflet, or excessive mid-ventricular or papillary muscle hypertrophy and malalignment (13,91,115).

Although it has previously been subject to periodic controversy (72,120,125,126), there is now widespread recognition that the subaortic gradient (30 mm Hg or more) and associated elevations in intra-cavity LV pressure reflect true mechanical impedance to outflow and are of pathophysiologic and prognostic importance to patients with HCM (127,128). Indeed, outflow obstruction is a strong, independent predictor of disease progression to HCM-related death (relative risk vs. nonobstructed patients, 2.0), to severe symptoms of New York Heart Association (NYHA) class III or IV, and to death due specifically to heart failure and stroke (relative risk vs. nonobstructed patients, 4.4) (127). However, the likelihood of severe symptoms and death from outflow tract obstruction was not greater when the gradient was increased in magnitude above the threshold of 30 mm Hg (127).

Disease consequences related to chronic outflow gradients are likely to be mediated by the resultant increase in LV wall stress, myocardial ischemia and eventually cell death and replacement fibrosis (7,127,129). Therefore, the presence of LV outflow obstruction justifies intervention to reduce or abolish significant subaortic gradients in severely symptomatic patients who are refractory to maximum medical management (11,14,41,127).

Obstruction in HCM is characteristically dynamic (i.e., not fixed): the magnitude (or even presence) of an outflow gradient may be spontaneously labile and vary considerably with a number of physiologic alterations as diverse as a heavy meal or ingestion of a small amount of alcohol (72,73,109). Different gradient cut-offs have been proposed for segregating individual patients into hemodynamic subgroups, but rigorous partitioning into such hemodynamic categories according to gradient can be difficult because of the unpredictable dynamic changes that may occur in individual patients (72,73).

Nevertheless, it is reasonable to divide the overall HCM disease spectrum into hemodynamic subgroups, based on the representative peak instantaneous gradient as assessed with continuous wave Doppler: 1) obstructive gradient under basal (resting) conditions equal to or greater than 30 mm Hg (2.7 m/s by Doppler), 2) latent (provocable) obstructive—gradient less than 30 mm Hg under basal conditions and equal to or greater than 30 mm Hg with provocation, and 3) nonobstructive—less than 30 mm Hg under both basal and (provocable) conditions. By current clinical convention, LV outflow gradients are routinely measured noninvasively with continuous wave Doppler echocardiography, generally obviating the need for serial cardiac catheterizations in this disease (except when atherosclerotic CAD or other associated anomalies such as intrinsic valvular disease are suspected).

It is important to underscore that a variety of interventions have been traditionally employed to elicit latent (inducible) gradients in the echocardiography, cardiac catheterization, and exercise laboratories (i.e., amyl nitrite inhalation, Valsalva maneuver, post-premature ventricular contraction response, isoproterenol or dobutamine infusion, standing posture, and physiologic exercise) (3,72,73), however, rigorous standardization for these maneuvers has been lacking, and many have come to be regarded as non-physiologic. To define latent gradients during and/or immediately following exercise for the purpose of major management decisions, treadmill or bicycle exercise testing in association with Doppler echocardiography is probably the most physiologic and preferred provocative maneuver, given that HCM-related symptoms are typically elicited with exertion. Intravenous administration of dobutamine is undesirable (130,131), as discussed under the section on alcohol septal ablation.

	Genetics and molecular diagnosis

Top Table of contents Preamble Introduction General considerations and... Nomenclature, definitions, and... Obstruction to LV outflow Genetics and molecular diagnosis General considerations for... Symptoms and pharmacological... Treatment options for drug... Surgery Additional approaches to relieve... Sudden cardiac death Atrial fibrillation References

 
Hypertrophic cardiomyopathy is inherited as a Mendelian autosomal dominant trait and is caused by mutations in any one of 10 genes, each encoding protein components of the cardiac sarcomere composed of thick or thin filaments with contractile, structural, or regulatory functions (6,9,17–19,64,65,132–139). It is possible to regard the diverse clinical spectrum as a single, unified disease entity and primary disorder of the sarcomere (18,63). Three of the HCM-causing mutant genes predominate in frequency—i.e., beta-myosin heavy chain (the first identified), myosin-binding protein C and cardiac troponin-T probably comprise more than one-half of the genotyped patients to date. Seven other genes each account for fewer cases: regulatory and essential myosin light chains, titin, alpha-tropomyosin, alpha-actin, cardiac troponin-I, and alpha-myosin heavy chain. This genetic diversity is compounded by intragenic heterogeneity, with about 200 mutations now identified (see http://genetics.med.harvard.edu/seidman/cg3), most of which are missense, with a single amino acid residue substituted with another (63). Indeed, molecular defects responsible for HCM are usually different in unrelated individuals, and many other mutations in previously identified genes (and even in additional genes, each probably accounting for a small proportion of familial HCM) undoubtedly remain to be identified.

Phenotypic expression of HCM (i.e., LVH) is the product not only of the causal mutation, but also of modifier genes and environmental factors (140,141). The magnitude of effect that modifier genes have on morphologic expression has not yet been systematically explored, but it can be inferred from the phenotypic variability of affected individuals in the same family carrying identical disease-causing mutations. As a result of the complexity of the molecular biology of hypertrophy, a large number of genes may influence the expression of the phenotype. There is also increasing recognition of the role of genetics in the genesis of electrophysiological abnormalities associated with LVH. For example, an increased risk for atrial fibrillation (AF) in HCM has been identified with a beta-myosin heavy chain Arg663 His mutation (136).

Missense mutations in the gene encoding the gamma-2-regulatory subunit of the AMP-activated protein kinase (PRKAG2), a regulator of cellular energy homeostasis, have been reported to cause familial LVH associated with ventricular pre-excitation (134,142). Absence of classical histopathology such as myocyte disarray, a distinct molecular cause for LVH (in part, reflecting glycogen accumulation in myocytes), and progressive conduction system disease and heart block distinguish PRKAG2 from sarcomere protein gene mutations typical of HCM (142). Indeed, this syndrome is probably most appropriately regarded as a metabolic storage disease distinct from true HCM. Therefore, it may not be optimal to base management and clinical risk assessment of patients with cardiac hypertrophy and Wolff-Parkinson-White on the data derived from patients with HCM. Also, thickening of the LV wall resembling HCM occurs in children (and some adults) with other disease states—e.g., Noonan's syndrome, mitochondrial myopathies, Friedreich's ataxia, metabolic disorders, Anderson-Fabry disease (X-linked deficiency of the lysosomal enzyme alpha-galactosidase) (143,144), LV non-compaction (145), and cardiac amyloidosis (110).

Molecular genetic studies over the past decade have underscored and provided important insights into the profound clinical and genetic heterogeneity of HCM, including the power to achieve preclinical diagnosis of individuals who are affected by a mutant gene but who show no evidence of the disease phenotype on a two-dimensional echocardiogram (or electrocardiogram [ECG]) (6,17,57,64,65,146,147). Indeed, HCM may be even more common in the general population than the cited prevalence of 1:500 (based on recognition of the established phenotype by echocardiography) (1) because of incomplete, time-dependent, variable expression of the disease phenotype and because many affected individuals have not been clinically recognized and are not represented in general cardiologic practice, where the disease is relatively uncommon (50). In the clinical assessment of individual pedigrees, it is obligatory for the proband to be informed of the familial nature and autosomal dominant transmission of HCM.

Not all individuals harboring a genetic defect will express the clinical features of HCM (e.g., LVH on echocardiogram, abnormal ECG pattern or disease-related symptoms) at all times during life, and 12-lead ECG abnormalities or evidence of diastolic dysfunction assessed by Doppler tissue imaging may even precede the appearance of the phenotype on echocardiogram especially in the young (148–151). Indeed, clinical and molecular genetic studies have demonstrated that there is in fact no minimum LV wall thickness required to be consistent with the presence of an HCM-causing mutant gene (17,65,146–148,152). For example, it is common for children less than 13 years old to be affected "silent" mutation carriers without evidence of LVH on an echocardiogram. Most commonly, substantial LV remodeling with the spontaneous appearance of LVH occurs associated with accelerated body growth and maturation during the adolescent years and with morphologic expression usually completed at the time physical maturity is achieved (about 17 to 18 years) (150,152,153).

Furthermore, novel diagnostic criteria for HCM have recently emerged, based on genotype-phenotype studies showing that incomplete penetrance and disease expression with absence of (or minimal) LVH may occur in adult individuals (most commonly due to cardiac myosin-binding protein-C or troponin-T mutations) (17,19,65,135,149,151). In both cross-sectional (17) and serial echocardiographic studies (65), mutations in myosin-binding protein C gene have demonstrated age-related penetrance and late-onset of the phenotype in which delayed and de novo appearance of LVH on echocardiogram occurs in mid-life and even later. Therefore, the traditional tenet that held that a normal echocardiogram (and ECG) obtained after full growth has been achieved defined a genetically unaffected relative has been revised. Such late-onset adult morphologic conversions dictate that it is no longer possible, based solely on a normal echocardiogram and ECG, to issue definitive reassurance to asymptomatic family members at maturity (or even in middle-age) that they are free of a disease-causing mutant HCM gene.

Clinical screening of first-degree relatives and other family members should be encouraged. Therefore, when a DNA-based diagnosis is not feasible, the recommended clinical strategies for screening family members employ history and physical examination, 12-lead ECG, and two-dimensional echocardiography at annual evaluations during adolescence (12 to18 years of age). Due to the possibility of delayed adult-onset LVH, it is reasonable and prudent to recommend that adult relatives with normal echocardiograms at or beyond age 18 have subsequent clinical studies performed about every five years. Screening in relatives younger than age 12 is not usually pursued systematically unless the child has a high-risk family history or is involved in particularly intense competitive sports programs. Affected patients identified through family screening (or otherwise) are conventionally evaluated on approximately a 12- to 18-month basis, as described under Risk Stratification and Sudden Cardiac Death heading.

Laboratory DNA analysis for mutant genes is the most definitive method for establishing the diagnosis of HCM. At present, however, there are several obstacles to the translation of genetic research into practical clinical applications and routine clinical strategy. These include the substantial genetic heterogeneity, the low frequency with which each causal mutation occurs in the general HCM population, and the important methodologic difficulties associated with identifying a single disease-causing mutation among 10 different genes in view of the complex, time-consuming, and expensive laboratory techniques involved. Mutation analysis is presently confined to a few research-oriented laboratories. The current development of better methodologies for automated, direct DNA sequencing and indirect approaches for sequence profiling now provides sensitive techniques that can accurately define the molecular cause for HCM in a single proband, without involving family members or complex linkage analysis in large pedigrees. However, the large number and size of the genes that may need to be examined in each proband continue to limit the efficiency of a gene-based diagnosis. However, once a mutation is defined in a proband, an accurate definition of genetic status in all family members is both efficient and inexpensive.

Although there is interest in the application of gene therapy to a variety of inheritable human conditions, at this time the clinical utilization of this technology in HCM is extremely problematic. Hypertrophic cardiomyopathy is transmitted as an autosomal dominant trait, and affected persons possess one mutated and one normal allele. Because most mutations in this disease cause substitution of a single amino acid within the encoded protein, gene therapy would theoretically have the daunting task of selectively targeting and inactivating the mutated gene, the encoded protein, or both. Furthermore, selection of patients for gene therapy would be particularly complex given that some forms of the disease are compatible with normal longevity and absence of symptoms. Also, such therapeutic interventions would presumably be applicable only to a small patient subset consisting of very young affected members from high-risk families identified prior to the development of LVH. Spontaneous animal models of HCM (154), or model organisms including mice and rabbits, may foster the development of pharmacologic therapies that reduce disease manifestations, including hypertrophy and interstitial (matrix) fibrosis (155–158).

	General considerations for natural history and clinical course

Top Table of contents Preamble Introduction General considerations and... Nomenclature, definitions, and... Obstruction to LV outflow Genetics and molecular diagnosis General considerations for... Symptoms and pharmacological... Treatment options for drug... Surgery Additional approaches to relieve... Sudden cardiac death Atrial fibrillation References

 
Hypertrophic cardiomyopathy is a unique cardiovascular disease with the potential for clinical presentation during any phase of life from infancy to old age (day one to over 90 years). The clinical course is typically variable, and patients may remain stable over long periods of time with up to 25% of a HCM cohort achieving normal longevity (75 years of age or older) (7,30,31,34,159). However, the course of many patients may be punctuated by adverse clinical events, largely related to sudden, unexpected death, embolic stroke, and the consequences of heart failure (5,7,29,30,38). Hypertrophic cardiomyopathy is also a rare cause of severe heart failure in infants and very young children, and presentation in this age group itself constitutes an unfavorable prognostic sign (53,58).

In general, adverse clinical course proceeds along one or more of several of the following pathways, which ultimately dictate treatment strategies (Figs. 1 and 2) (5,7,11,14,26): 1) high risk for premature sudden and unexpected death; 2) progressive symptoms largely of exertional dyspnea, chest pain (either typical of angina or atypical in nature), and impaired consciousness, including syncope, near-syncope or presyncope (i.e., dizziness/lightheadedness), in the presence of preserved LV systolic function; 3) progression to advanced congestive heart failure (the "end-stage phase") with LV remodeling and systolic dysfunction (37,160); and 4) complications attributable to AF, including embolic stroke (38,161–163).

View larger version (47K): [in this window] [in a new window]   Figure 1 Clinical presentation and treatment strategies for patient subgroups within the broad clinical spectrum of hypertrophic cardiomyopathy (HCM). See text for details. AF = atrial fibrillation; DDD=dual-chamber; ICD = implantable cardioverter-defibrillator; SD = sudden death. Adapted with permission (11). *No specific treatment or intervention indicated, except under exceptional circumstances.

View larger version (103K): [in this window] [in a new window]   Figure 2 The principal pathways of disease progression in hypertrophic cardiomyopathy (HCM). Widths of the respective arrows approximate the frequency with which the pathway occurs in HCM populations. AF = atrial fibrillation.

Over-dependence on frequently cited, ominous mortality rates of 3% to 6% per year for HCM-related premature death from tertiary centers may have led to an exaggeration of the overall risk and impact of this disease on patients and, thereby, contributed to a misguided perception that HCM is invariably an unfavorable disorder with inevitable, adverse consequences frequently requiring major therapeutic intervention (7,59,165). However, more recent reports from non-tertiary centers with fewer selected, regional, and community-based cohorts not subject to tertiary center referral bias are probably more representative of the overall disease state, citing annual mortality rates in a much lower range of about 1%, with the survival of patients not dissimilar to that of the general adult U.S. population (7,30,31). Nevertheless, of note, there are subgroups of patients within the broad HCM spectrum with annual mortality rates far exceeding 1% and conform to the rates of up to 6% per year previously attributed to the overall disease (7,11,41,165,166).

Hypertrophic cardiomyopathy attributable to sarcomere protein mutations also occurs in the elderly (139) and should be distinguished from non-genetic hypertensive heart disease or age-related changes in persons of advanced age. The determinants of extended survival in some patients with HCM are largely unresolved. It is possible that benign genetic substrates may convey favorable prognosis and normal life expectancy. However, at present, genotype data are available for only a limited number of elderly patients, with mutations in the cardiac myosin-binding protein C gene being most common (139). Older patients with HCM characteristically show relatively mild degrees of LVH and may not experience severe symptoms. Some even have large resting subaortic gradients that are often caused by the SAM-septal contact associated with normal-sized mitral leaflets greatly displaced anteriorly, seemingly by calcium accumulation posteriorly in the mitral annulus, within a particularly small LV outflow tract (167). Definitive clinical diagnosis of HCM in older patients with LVH and systemic hypertension is often difficult to resolve, particularly when LV wall thickness is less than 20 mm and SAM is absent. In the absence of genotyping, marked LVH disproportionate to the level of blood pressure elevation, unusual patterns of LVH unique to HCM (36), or an obstruction to LV outflow at rest represents presumptive evidence for HCM (127).

Not uncommonly, HCM coexists with other cardiac conditions such as systemic hypertension and/or CAD. In such patients, the management of HCM should be considered independent of any co-morbidity, and each of the disease entities should be treated on its own merit. For example, specific concerns that may arise include avoidance of angiotensin-converting enzyme (ACE) inhibitors to control hypertension in the presence of HCM-related resting or provocable LV outflow tract obstruction and failure to exclude the diagnosis of CAD in those HCM patients with angina pectoris.

In summary, it is probably most appropriate to regard HCM as a complex disease capable of producing important clinical consequences and premature death in some patients, while many other patients reach normal longevity and life expectancy with mild or no disability and without major therapeutic interventions. Many individuals affected by HCM may not require treatment for most or all of their natural lives, and they therefore deserve reassurance with regard to their prognosis.

	Symptoms and pharmacological management strategies

Top Table of contents Preamble Introduction General considerations and... Nomenclature, definitions, and... Obstruction to LV outflow Genetics and molecular diagnosis General considerations for... Symptoms and pharmacological... Treatment options for drug... Surgery Additional approaches to relieve... Sudden cardiac death Atrial fibrillation References

 
A fundamental goal of treatment in HCM is the alleviation of symptoms related to heart failure (Fig. 1). Pharmacological therapy has traditionally been the initial therapeutic approach for relieving disabling symptoms of exertional dyspnea (with or without associated chest pain) and improving exercise capacity for more than 35 years, since the introduction of beta-blockers in the mid-1960s (3,10,14,168–179). Also, drugs are often the sole therapeutic option available to the many patients without obstruction to LV outflow, under resting or provocable conditions, who constitute a substantial proportion of the HCM population. Indeed, it is the convention to empirically initiate pharmacologic therapy when symptoms of exercise intolerance intervene, although there have been few randomized trials to compare the effect of drugs in HCM (5,7,11,179) (Fig. 1).

Exertional dyspnea and disability (often associated chest pain), dizziness, presyncope and syncope usually occur in the presence of preserved systolic function and a nondilated LV (5,7,11,14,180). Symptoms appear to be caused in large measure by diastolic dysfunction with impaired filling due to abnormal relaxation and increased chamber stiffness, leading in turn to elevated left atrial and LV end-diastolic pressures (with reduced stroke volume and cardiac output) (181–188), pulmonary congestion, and impaired exercise performance with reduced oxygen consumption at peak exercise (189).

The pathophysiology of such symptoms, due to this form of diastolic heart failure, may also be intertwined with other important pathophysiologic mechanisms such as myocardial ischemia (190–201), outflow obstruction associated with mitral regurgitation (13,127), and AF (163). Indeed, many patients may experience symptoms largely from diastolic dysfunction or myocardial ischemia in the absence of outflow obstruction (or severe hypertrophy). Other patients (i.e., those with LV outflow obstruction) are more disabled by elevated LV pressures and concomitant mitral regurgitation than by diastolic dysfunction, as is evidenced by the often dramatic symptomatic benefit derived from major therapeutic interventions that reduce or obliterate outflow gradient (most frequently myectomy or alcohol ablation) (7,13–15,49,81,83–88,90–95,102–106,202).

Chest pain in the absence of atherosclerotic CAD may be typical of angina pectoris or atypical in character. Most chest discomfort is probably due by bursts of myocardial ischemia, evidenced by the findings of scars at autopsy (51,195,199,203), fixed or reversible myocardial perfusion defects and the suggestion of scarring by magnetic resonance imaging (129), net lactate release during atrial pacing, and impaired coronary vasodilator capacity (190,192,193,198,201,204). Myocardial ischemia is probably a consequence of abnormal microvasculature, consisting of intramural coronary arterioles with thickened walls (from medial hypertrophy) and narrowed lumen (195–201), and/or a mismatch between the greatly increased LV mass and coronary flow. Because typical anginal chest pain may be part of the HCM symptom-complex, associated atherosclerotic CAD (which may complicate clinical course) is often overlooked in these patients. Therefore, coronary arteriography is indicated in patients with HCM and persistent angina who are over 40 years of age or who have risk factors for CAD, or when CAD is judged possible prior to any invasive treatment for HCM such as septal myectomy (or alcohol septal ablation).

Beta-adrenergic blocking agents.   Beta-blockers are negative inotropic drugs that have traditionally been administered to HCM patients with or without obstruction, usually relying on the patient's own subjective and historical perception of benefit (11,14,168,169,172,179). However, judgments regarding treatment strategies in HCM with beta-blockers are often difficult, taking into account the frequent day-to-day variability in magnitude of symptoms. Treadmill or bicycle exercise—with or without measurement of peak oxygen consumption (189)—have proved helpful in targeting patients for therapy or determining when changes in dosage or drugs are appropriate. If limiting symptoms progress, drug dosage may be increased within the accepted therapeutic range. Patient responses to drugs are highly variable in terms of magnitude and duration of benefit, and the selection of medications has not achieved widespread standardization and has been dependent, in part, on the experiences of individual practitioners, investigators, and centers.

Propranolol was the first drug used in the medical management of HCM, and long-acting preparations of propranolol or agents such as atenolol, metoprolol, or nadolol have been employed more recently. There are many reports of subjective symptomatic improvement and enhanced exercise capacity in a dose range of up to 480 mg per day for propranolol (2 mg/kg in children), both in patients with and without outflow obstruction. Although some investigators have administered massive doses of propranolol (up to 1,000 mg per day), claiming symptomatic benefit and long-term survival without major side effects (172), this is not generally accepted practice. However, even moderate doses of beta-blockers may affect growth in young children or impair school performance, or trigger depression in children and adolescents, and should be closely monitored in such patients.

Substantial experience suggests that standard dosages of these drugs can mitigate disabling symptoms and limit the latent outflow gradient provoked during exercise when sympathetic tone is high and heart failure symptoms occur. However, there is little evidence that beta-blocking agents consistently reduce outflow obstruction under resting conditions. Consequently, beta-blockers are a preferred drug treatment strategy for symptomatic patients with outflow gradients present only with exertion.

The beneficial effects of beta-blockers on symptoms of exertional dyspnea and exercise intolerance appear to be attributable largely to a decrease in the heart rate with a consequent prolongation of diastole and relaxation and an increase in passive ventricular filling. These agents lessen LV contractility and myocardial oxygen demand and possibly reduce microvascular myocardial ischemia. Potential side effects include fatigue, impotence, sleep disturbances, and chronotropic incompetence.

Verapamil.   In 1979, the calcium antagonist verapamil was introduced as another negative inotropic agent for the treatment of HCM (170), and has been widely used empirically in both the nonobstructive and obstructive forms, with a reported benefit for many patients, including those with a component of chest pain (176,205,206). Verapamil in doses up to 480 mg per day (usually in a sustained release preparation) has favorable effects on symptoms, probably by virtue of improving ventricular relaxation and filling as well as relieving myocardial ischemia and decreasing LV contractility (181,182,206). However, aside from the mild side effect of constipation, verapamil may also occasionally harbor a potential for clinically important adverse consequences and has been reported to cause death in a few HCM patients with severe disabling symptoms (orthopnea and paroxysmal nocturnal dyspnea) and markedly elevated pulmonary arterial pressure in combination with marked outflow obstruction (14). Adverse hemodynamic effects of verapamil are presumably the result of the vasodilating properties predominating over negative inotropic effects, resulting in augmented outflow obstruction, pulmonary edema, and cardiogenic shock. Because of these concerns, caution should be exercised in administering verapamil to patients with resting outflow obstruction and severe limiting symptoms. Some investigators discourage the use of calcium antagonists in the management of obstructive HCM and instead favor disopyramide (often with a beta-blocker) for such patients with severe symptoms (14,173). Verapamil is not indicated in infants due to the risk for sudden death that has been reported with intravenous administration. Dosages of oral verapamil have not been established for infants and preadolescent children.

Most clinicians favor using beta-blockers over verapamil for the initial medical treatment of exertional dyspnea, although it does not appear to be of crucial importance which drug is administered first. It has been common practice, however, to administer verapamil to those patients who do not experience a benefit from beta-blockers or who have a history of asthma. Improvement with verapamil may be due to the primary actions of the drug, and in some instances, partially attributable to withdrawal of beta-blockers and the abolition of side effects that evolved insidiously over time. At present, there is no evidence that combined medical therapy with administration of beta-blockers and verapamil is more advantageous than the use of either drug alone.

Disopyramide.   The negative inotropic and type I-A antiarrhythmic agent disopyramide was introduced into the treatment regimen for patients with obstructive HCM in 1982. There are reports of disopyramide producing symptomatic benefit (at 300 to 600 mg per day with a dose-response effect) in severely limited patients with resting obstruction, because of a decrease in SAM, outflow obstruction, and mitral regurgitant volume (168,171,173,174,177). Anti-cholinergic side effects such as dry mouth and eyes, constipation, indigestion, and difficulty in micturition may be reduced by long-acting preparations through which cardioactive benefits are more sustained. Because disopyramide may cause accelerated atrioventricular (A-V) nodal conduction and thus increase ventricular rate during AF, supplemental therapy with beta-blockers in low doses to achieve normal resting heart rate has been advised.

Although disopyramide incorporates antiarrhythmic properties, there is little evidence that proarrhythmic effects have intervened in HCM patients. Nevertheless, this issue remains of some concern in a disease associated with an arrhythmogenic LV substrate; prolongation of the QT interval should be monitored while administering the drug. Furthermore, disopyramide administration may be deleterious in nonobstructive HCM by decreasing cardiac output, causing most investigators to limit its use to patients with outflow obstruction who have not responded to beta-blockers or verapamil.

At present, the information regarding drugs such as sotalol and other calcium antagonists (such as diltiazem) is insufficient to recommend their use in HCM. Diuretic agents may be added to the cardioactive drug regimen prudently—preferably in the absence of marked outflow obstruction. Because many patients have diastolic dysfunction and require relatively high filling pressures to achieve adequate ventricular filling, it may be advisable to administer diuretics cautiously. Nifedipine, because of its particularly potent vasodilating properties, may be deleterious, particularly for patients with outflow obstruction. Combined therapy with disopyramide and amiodarone (or disopyramide and sotalol), or quinidine and verapamil (or quinidine and procainamide), should also be avoided due to concern over proarrhythmia; also, administration of nitroglycerine, ACE inhibitors or digitalis are generally contraindicated or discouraged in the presence of resting or provocable outflow obstruction. In patients with severe heart failure refractory to other medications, caution is advised in administrating amiodarone in a high dosage (greater than or equal to 400 mg per day). In patients with erectile dysfunction, phosphodiesterase inhibitors should be used with the awareness that a mild afterload reducing effect may be deleterious in patients with resting or provocable obstruction.

Drugs in end-stage phase.   A small but important subgroup of patients with nonobstructive HCM develops systolic ventricular dysfunction and severe heart failure, usually associated with LV remodeling demonstrable as wall thinning and chamber enlargement. This particular evolution of HCM occurs in only about 5% of patients and has been variously known as the "end-stage," "burnt-out," or "dilated" phase (7,37,160). Drug treatment strategies in such patients with systolic failure differ substantially from those approaches in HCM patients with typical LVH, nondilated chambers, and preserved systolic function (i.e., involving conversion to after load-reducing agents such as ACE inhibitors or angiotensin-II receptor blockers or diuretics, digitalis, beta-blockers or spironolactone) (Fig. 1). There is no evidence, however, that beta-blockers prevent or convey a benefit to congestive heart failure and ventricular systolic dysfunction of the "end-of-stage" (by contrast with the experience in dilated cardiomyopathy and CAD). Ultimately, patients with end-stage heart failure may become candidates for heart transplantation, and they represent the primary subgroup within the broad disease spectrum of HCM for when this treatment option is considered (207) (Fig. 1).

Asymptomatic patients.   Data from largely unselected cohorts and genotyping studies in families suggest that most HCM patients, including many who are not even aware of their disease, probably have no symptoms or only mild symptoms (5–7,17–19,30,50,55,59,64,65,164). While most of the asymptomatic patients do not require treatment, some represent therapeutic dilemmas because of their youthful age and the consideration for prophylactic therapy to prevent SCD or disease progression (21,27,127,208,209).

Prophylactic drug therapy in asymptomatic (or mildly symptomatic) patients to prevent or delay development of symptoms and improve prognosis has been the subject of debate for many years, but it remains on an entirely empiric basis without controlled data to either support or contradict its potential efficacy (11). This issue is unresolved due to the relatively small patient populations previously available for study, as well as the infrequency with which adverse end points occur prematurely in this disease. Additionally, there is a growing awareness that an important proportion of HCM patients achieve normal life expectancy (30–32,34,55). In general, treatments to delay or prevent progression of the disease due to heart failure-related symptoms are most appropriately directed toward relieving LV outflow tract obstruction and controlling or abolishing AF through pharmacologic or intervention-based strategies. Indeed, treatments targeted at aborting the disease progression are now confined to those patients judged to be at high-risk for SCD (as discussed under Risk Stratification and Sudden Cardiac Death). The efficacy of empiric, prophylactic drug treatment with beta-blockers, verapamil or disopyramide for delaying the onset of symptoms and favorably altering the clinical course or outcome in asymptomatic young patients with particularly marked LV outflow tract gradients (about 75 to 100 mm Hg or more) is unresolved.

Infective endocarditis prophylaxis.   In HCM there is a small risk for bacterial endocarditis, which appears largely confined to those patients with LV outflow tract obstruction under resting conditions or with intrinsic mitral valve disease (210). The site of the valvular vegetation is usually the thickened anterior mitral leaflet, although cases have been reported with lesions on the outflow tract endocardial contact plaque (at the point of mitral-septal contact) or on the aortic valve (210,211). Therefore, the AHA recommendation (212) should be applied to HCM patients with evidence of outflow obstruction under resting or exercise conditions at the time of dental or selected surgical procedures that create a risk for blood-borne bacteremia.

Pregnancy.   There is no evidence that patients with HCM are generally at increased risk during pregnancy and delivery. Absolute maternal mortality is very low (although possibly higher in patients with HCM than in the general population) and appears to be confined principally to women with high-risk clinical profiles (213). Such patients should be afforded highly specialized preventive obstetrical care during pregnancy. Otherwise, most pregnant HCM patients undergo normal vaginal delivery without the necessity for cesarean section.

	Treatment options for drug-refractory patients

Top Table of contents Preamble Introduction General considerations and... Nomenclature, definitions, and... Obstruction to LV outflow Genetics and molecular diagnosis General considerations for... Symptoms and pharmacological... Treatment options for drug... Surgery Additional approaches to relieve... Sudden cardiac death Atrial fibrillation References

 
In some patients, medical therapy ultimately proves insufficient to control symptoms, and the quality of life becomes unacceptable to the patient. At this point in the clinical course, after administration of maximum drug treatment, the subsequent therapeutic strategies are dictated largely by whether LV outflow obstruction is present (Fig. 1).

	Surgery

Top Table of contents Preamble Introduction General considerations and... Nomenclature, definitions, and... Obstruction to LV outflow Genetics and molecular diagnosis General considerations for... Symptoms and pharmacological... Treatment options for drug... Surgery Additional approaches to relieve... Sudden cardiac death Atrial fibrillation References

 
Patients in a small but important subgroup comprising only about 5% of all HCM patients in non-referral settings (but up to 30% in tertiary referral populations), are generally regarded as candidates for surgery. These patients have particularly marked outflow gradients (peak instantaneous usually greater than or equal to 50 mm Hg), as measured with continuous wave Doppler echocardiography either under resting/basal conditions and/or with provocation preferably utilizing physiologic exercise. In addition, these patients have severe limiting symptoms, usually of exertional dyspnea and chest pain that are regarded in adults as NYHA functional classes III and IV, refractory to maximum medical therapy (7,8,11,14,41,90,92,102,103). Over the past 40 years, based on the experience of a number of centers throughout the world, the ventricular septal myectomy operation (also known as the Morrow procedure) (8) has become established as a proven approach for amelioration of outflow obstruction and the standard therapeutic option, and the gold standard, for both adults and children with obstructive HCM and severe drug-refractory symptoms (7,11,14,15,41,70,78,81,84,85,90–95,102–106,214). The myectomy operation should be confined to centers experienced in this procedure.

Myectomy is performed through an aortotomy and involves the resection of a carefully defined relatively small amount of muscle from the proximal septum (about 5 to 10 g), extending from near the base of the aortic valve to beyond the distal margins of mitral leaflets (about 3 to 4 cm), thereby enlarging the LV outflow tract (215) and, as a consequence in the vast majority of patients, abolishing any significant mechanical impedance to ejection and mitral valve SAM immediately normalizing LV systolic pressures, abolishing mitral regurgitation, and ultimately, reducing LV end-diastolic pressures. Such an abrupt relief of the gradient with surgery (in contrast to slower reduction with alcohol septal ablation in many cases) is particularly advantageous in patients with severe functional limitations.

Some surgeons have utilized a more extensive myectomy procedure for obstructive HCM, with the septal resection widened and extended far more distally than in the classic Morrow procedure (i.e., 7 to 8 cm from the aortic valve to below the level of papillary muscles) (70,91). In addition, the anterolateral papillary muscle may be dissected partially free from its attachment with the lateral LV free wall to enhance papillary muscle mobility and reduce anterior tethering of the mitral apparatus (91). Alternatively, mitral valve replacement or repair has been employed in selected patients judged to have severe mitral regurgitation due to intrinsic abnormalities of the valve apparatus (such as myxomatous mitral valve) (124).

Previously, some surgeons found it advantageous in selected patients to perform mitral valve replacement (216,217) when the basal anterior septum in the area of resection is relatively thin (e.g., less than 18 mm) and muscular resection was judged to present an unacceptable risk of septal perforation or inadequate hemodynamic result (93). However, currently, some surgical centers experienced with myectomy do not advocate mitral valve replacement (in the absence of intrinsic mitral valve disease), even in the presence of a relatively thin ventricular septum; carefully performed surgical septal reduction is the preferred method.

Mitral valvuloplasty (plication) in combination with myectomy has been proposed for some patients with particularly deformed or elongated mitral leaflets (84). Muscular mid-cavity obstruction due to an anomalous papillary muscle requires an extended distal myectomy (91) or alternatively mitral valve replacement (115). Occasionally, patients, usually children, may demonstrate an obstruction to right ventricular outflow due to excessive muscular hypertrophy of trabeculae or crista supraventricularis muscle (218); resection of the right ventricular outflow tract muscle, with or without an outflow tract patch, has abolished the gradient.

Published reports of over 2,000 patients from North American and European centers show remarkably consistent results with the ventricular septal myectomy operation. Isolated myectomy (without concomitant cardiac procedures such as valve replacement or coronary artery bypass grafting) is now performed with low operative mortality in patients of all ages, including children, at those centers having the most experience with this procedure (reported as 1% to 3%, and even less in the most recent cases) (7,11,15,81,92–95,101–107). Surgical risk may be higher among very elderly patients (particularly those with severe disabling symptoms associated with pulmonary hypertension), patients with prior myectomy, or those undergoing additional cardiac surgical procedures. Complications such as complete heart block (requiring permanent pacemaker) and iatrogenic ventricular septal perforation have become uncommon (equal to or less than 1% to 2%), while partial or complete left bundle-branch block is an inevitable consequence of the muscular resection and is not associated with adverse sequelae (15,81,85,90–93,102–106). Intraoperative guidance with echocardiography (transesophageal or with the transducer applied directly to the right ventricular surface) is standard at centers performing surgery for HCM and is useful in assessing the site and extent of the proposed myectomy, structural features of the mitral valve, and the effect of muscular resection on SAM and mitral regurgitation (93,123,219).

Septal myectomy is associated with persistent, long-lasting improvement in disabling symptoms and exercise capacity (i.e., increase by one or more NYHA classes and demonstrable increase in peak oxygen consumption with exercise) and decreased frequency of syncope five or more years after surgery (7,11,13–15,81,90–95,102–106,220). Symptomatic benefit following myectomy appears to be largely the consequence of abolishing or substantially reducing the basal outflow gradient and mitral regurgitation, and restoring normal LV systolic and end-diastolic pressures (in more than 90% of patients), which may also favorably influence LV diastolic filling and myocardial ischemia (204). Because myectomy may result in a decrease in left atrial size (221), the likelihood of AF occurring after surgery may be mitigated (and sinus rhythm restored with greater ease), especially in patients younger than 45 years.

Selected patients in whom severe refractory symptoms are indisputably linked to marked outflow gradients elicited by exercise (when resting obstruction is absent or mild) usually also benefit from myectomy. Reacquisition of SAM and a large resting LV outflow gradient is exceedingly uncommon after successful myectomy in either adults or children, and the need for reoperation to reduce recurrent outflow gradient is extremely uncommon at centers having the most experience with the septal myectomy operation (15,81,95,103,105).

By convention, surgery has not been recommended or performed in asymptomatic or mildly symptomatic patients with obstructive HCM for a number of reasons: 1) the effect of surgery per se on longevity is unresolved, although several surgical series have reported improved late survival after myectomy compared with the clinical course of nonoperated medically treated patients with severe symptoms; 2) operative mortality is now very low, but in some patients the risk of surgery may exceed the ultimate risks from the disease; 3) outflow obstruction is often compatible with normal longevity; and 4) there is little or no evidence that surgical relief of outflow obstruction abolishes the risk for progression to the end-stage phase, which is an independent disease consequence.

Although definitive evidence is lacking, there is some suggestion in retrospective non-randomized studies that surgical relief of outflow obstruction in severely symptomatic patients may reduce long-term mortality and possibly SCD (10,95,105). It should be emphasized that surgery is not regarded as curative but is performed to achieve an improved quality of life and functional (exercise) capacity. One possible exception to this tenet may be young asymptomatic or mildly symptomatic patients with particularly marked outflow obstruction (e.g., 75 to 100 mm Hg or more at rest). There is a paucity of data in this subset, but it is not unreasonable to at least consider surgical intervention for young patients, even if they are not severely symptomatic, in the presence of particularly marked obstruction to LV outflow.

	Additional approaches to relieve