CORRESPONDENCE: LETTER TO THE EDITOR
Debating About a Registry to Define the Best Invasive Treatment for Obstructive Hypertrophic CardiomyopathyShould It Also Include Obstructive Patients Medically Treated?
Paolo Ferrazzi, MD, FETCS*,
Michele Triggiani, MD, PhD and
Attilio Iacovoni, MD
* Cardiovascular Department and Cardiac Surgery Unit, Ospedali Riuniti di Bergamo, Largo Barozzi 1, 24128, Bergamo, Italy (Email: pferrazzi{at}ospedaliriuniti.bergamo.it).
We have read with great interest the Viewpoint by Olivotto et al. (1) that recently was published in the Journal. The authors have convincingly demonstrated that a randomized prospective trial comparing the results of these 2 techniques is not feasible, because it would require the enrollment of more than 30,000 patients with hypertrophic cardiomyopathy. We agree with their conclusion that this issue can only be addressed by a large international multicenter registry.
However, in our opinion, the discussion on the respective advantages of surgical myectomy and alcohol septal ablation should not distract from the crucial and, still controversial, question of which patients are appropriate candidates for the myectomy operation. Indeed, the international guidelines on hypertrophic cardiomyopathy define candidates to myectomy as "both adults and children with obstructive hypertrophic cardiomyopathy and severe drug-refractory symptoms" (2). On the other hand, 2 recent retrospective studies performed in centers with a particularly large experience with the myectomy operation have shown that survival in patients with obstructive hypertrophic cardiomyopathy and heart failure symptoms who underwent myectomy is similar to that of patients with the nonobstructive form of the disease, and substantially more favorable than that of nonoperated obstructive patients (3,4). Both studies raise the important question of whether young patients with obstructive hypertrophic cardiomyopathy, a marked outflow gradient, and a dilated left atrium should be operated earlier, without waiting for the development of severe symptoms of heart failure unresponsive to medical treatment. On the basis of these recent results, cardiac surgeons with a large experience and very low operative mortality for the myectomy operation are now confronted with the dilemma of whether to operate young patients with outflow obstruction earlier in their clinical course, without waiting for progression to severe heart failure symptoms.
Therefore, we would like to take this opportunity to stress the need for a large international multicenter registry of the clinical course and management of patients with the obstructive form of hypertrophic cardiomyopathy, focused not only on the comparison of the results of myectomy operation versus alcohol septal ablation, but also on the selection of the proper candidates to surgery.
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1. Olivotto I, Ommen SR, Maron MS, Cecchi F, Maron BJ. Surgical myectomy versus alcohol septal ablation for obstructive hypertrophic cardiomyopathy J Am Coll Cardiol 2007;28:831-833.2. Maron BJ, McKenna WJ, Danielson GK, et al. 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. J Am Coll Cardiol 2003;42:1687-1713.[Free Full Text] 3. Ommen SR, Maron BJ, Olivotto I, Nishimura RA, et al. Long-term effects of surgical septal myectomy on survival in patients with obstructive hypertrophic cardiomyopathy J Am Coll Cardiol 2005;46:470-476.[Abstract/Free Full Text] 4. Woo A, Williams WG, Choi R, Wigle ED, et al. Clinical and echocardiographic determinants of long-term survival after surgical myectomy in obstructive hypertrophic cardiomyopathy Circulation 2005;111:2033-2041.[Abstract/Free Full Text]
Related Article
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Reply
- Iacopo Olivotto, Steve R. Ommen, Martin S. Maron, Franco Cecchi, and Barry J. Maron
J. Am. Coll. Cardiol. 2008 51: 1234-1235.
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