CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Iacopo Olivotto, MD*,
Steve R. Ommen, MD,
Martin S. Maron, MD,
Franco Cecchi, MD and
Barry J. Maron, MD
* Cardiologia San Luca, Referral Center for Cardiomyopathies, Azienda Ospedaliera Universitaria Careggi, Viale Pieraccini 17, Florence, Florence 50132, Italy (Email: olivottoi{at}ao-careggi.toscana.it).
We are grateful to Dr. Ferrazzi and colleagues for their thoughtful comments and interest in our work (1). The primary issue raised in their letter is indeed an important one; should surgical septal myectomy for obstructive hypertrophic cardiomyopathy (HCM) be offered to patients with less than severe drug-refractory symptoms, instead of waiting for the progression to New York Heart Association (NYHA) functional class III to IV? At this time, however, we believe that there is no compelling evidence to allow for such radical liberalization of the established selection criteria for surgical septal myectomy (or alcohol septal ablation) (2).
For example: 1) Patients with NYHA functional class III to IV symptoms of heart failure improve measurably after myectomy, often achieving functional class I (2–4). Obviously, symptomatic improvement cannot represent a clinical target in NYHA functional class I to II patients. 2) Postoperatively, patients with class III to IV symptoms have a long-term survival benefit equivalent to that of the general population (4). 3) There are few (if any) available data documenting irreversible heart failure despite adequate myectomy, due to an excessive period of NYHA functional class III to IV symptoms. 4) No consistent data support the advantage of myectomy in reducing left atrial size and the propensity for atrial fibrillation (2,5). For example, in the paper by Woo et al. (3), a substantial proportion of operated patients still went on to develop atrial fibrillation during follow-up.
On the other hand, we agree with Dr. Ferrazzi and colleagues that is probably not necessary or advisable to require symptomatic patients with obstructive HCM to prolong decisions regarding operative intervention until they are essentially disabled. Indeed, once symptoms related to obstruction become fixed and unresponsive to conventional pharmacologic treatment, further medical treatment is unlikely to result in clinical improvement equivalent to that expected following myectomy.
Finally, it is tantalizing to consider earlier intervention with surgical myectomy, given the very low operative mortality now reported by major centers (4). Nevertheless, we hesitate to promote myectomy for asymptomatic or mildly symptomatic patients with obstructive HCM, given that open-heart procedures are never without a mortality and morbidity risk, even at particularly experienced centers (2,4,5). Therefore, we welcome the suggestion of expanding the multicenter registry for obstructive HCM that we have proposed, as a tool to identify ideal candidates for septal reduction therapies (1). However, such registry may ultimately prove of limited value in establishing the need for earlier intervention in HCM patients.
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References
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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 J Am Coll Cardiol 2003;42:1687-1713.[Free Full Text] 3. 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;26:1112033–41. 4. Maron BJ. Controversies in cardiovascular medicine. Surgical myectomy remains the primary treatment option for severely symptomatic patients with obstructive hypertrophic cardiomyopathy. Circulation 2007;116:196-206.[Free Full Text] 5. Ommen SR, Maron BJ, Olivotto I, 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] 6. Olivotto I, Cecchi F, Casey SA, Dolara A, Traverse JH, Maron BJ. Impact of atrial fibrillation on the clinical course of hypertrophic cardiomyopathy Circulation 2001;104:2517-2524.[Abstract/Free Full Text]
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Debating About a Registry to Define the Best Invasive Treatment for Obstructive Hypertrophic Cardiomyopathy: Should It Also Include Obstructive Patients Medically Treated?
- Paolo Ferrazzi, Michele Triggiani, and Attilio Iacovoni
J. Am. Coll. Cardiol. 2008 51: 1233-1234.
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