CORRESPONDENCE: LETTERS TO THE EDITOR
Reply
Barry J. Maron, MD*,
Joseph A. Dearani, MD,
Steve R. Ommen, MD,
Martin S. Maron, MD,
Bernard J. Gersh, MB, ChB, DPhil and
Rick A. Nishimura, MD, FACC
* Minneapolis Heart Institute Foundation, 920 East 28th Street, Suite 60, Minneapolis, MN 55407 (Email: hcm.maron{at}mhif.org).
We agree completely with Ms. Salberg’s views regarding the recently published point-counterpoint comparing surgical septal myectomy and alcohol septal ablation in the management of obstructive hypertrophic cardiomyopathy (HCM) (1,2). Ms. Salberg asserts that Drs. Hess and Sigwart have been unfair and misleading by arbitrarily expunging surgery from their HCM treatment algorithm. Surely, a debate on this important controversy is both warranted and timely, but it is incumbent on all clinicians to approach the problem with measured judgment and prudence—for there is much at stake. The central issue is simply the optimal therapy for the individual patient with obstructive HCM.
We believe that we have met this threshold honorably in presenting the case for surgery (1). Conversely, we share Ms. Salberg’s substantial reservations regarding the brief counterpoint (2) in which Drs. Hess and Sigwart chose to literally obliterate surgery from consideration as a treatment option, as clearly evident in their prominent Figure 1. In the recent American College of Cardiology/European Society of Cardiology (ACC/ESC) expert consensus panel recommendations for HCM (3), septal myectomy is stipulated as the primary and "gold standard" treatment option for HCM patients with outflow obstruction and severe drug-refractory symptoms.
Publication of a point-counterpoint on the management of obstructive HCM was intended to be a fair presentation of divergent views—that is, pro and con, with one side presenting the case for surgery and the other supporting ablation, each contrasting their treatment of choice with the alternative strategy. However, the decision of Drs. Hess and Sigwart to intentionally leave the readership with a distinct impression that surgery is now obsolete is not only intellectually questionable but also very misleading to the HCM patient population and those practicing cardiologists charged with the role of gatekeeper in referring HCM patients for major interventions—such as surgery or ablation. This is particularly relevant given that myectomy is now associated with lower mortality (and morbidity) than alcohol ablation (1,3,4), and the recognition that arrhythmic sudden death can be a not uncommon consequence of ablation (4,5).
It is our absolute obligation to provide both physicians and patients with complete information regarding all the standard therapeutic options for drug-refractory severe obstructive HCM, and to avoid arbitrarily deciding for patients what they should (or should not) know, based on personal and unsubstantiated physician biases.
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References
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1. Maron BJ, Dearani JA, Ommen SR, et al. The case for surgery in obstructive hypertrophic cardiomyopathy J Am Coll Cardiol 2004;44:2044-2053.[Abstract/Free Full Text]
2. Hess OM, Sigwart U. New treatment strategies for hypertrophic cardiomyopathy: alcohol ablation of the septum: the new gold standard? J Am Coll Cardiol 2004;44:2054-2055.[Abstract/Free Full Text]
3. Maron BJ, McKenna WJ, Danielson GK, et al. American College of Cardiology/European Society of Cardiology clinical expert consensus document on hypertrophic cardiomyopathy J Am Coll Cardiol 2003;42:1687-1713.[Free Full Text]
4. Maron BJ. Surgery for obstructive hypertrophic cardiomyopathyalive and quite well. Circulation 2005;111:2016-2018.[Free Full Text]
5. Crawford FA, Killip D, Franklin J, et al. Implantable cardioverter-defibrillators for primary prevention of sudden cardiac death in patients with hypertrophic obstructive cardiomyopathy after alcohol septal ablation(abstr) Circulation 2003;108:IV386-IV387.
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