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J Am Coll Cardiol, 2007; 50:831-834, doi:10.1016/j.jacc.2007.05.018 (Published online 10 August 2007).
© 2007 by the American College of Cardiology Foundation
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VIEWPOINT

Surgical Myectomy Versus Alcohol Septal Ablation for Obstructive Hypertrophic Cardiomyopathy

Will There Ever Be a Randomized Trial?

Iacopo Olivotto, MD*,*, Steve R. Ommen, MD{dagger}, Martin S. Maron, MD§, Franco Cecchi, MD* and Barry J. Maron, MD{ddagger}

* Referral Center for Myocardial Diseases, Department of Cardiology, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
{dagger} Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
{ddagger} Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
§ Cardiology Division, Tufts–New England Medical Center, Boston, Massachusetts

Manuscript received November 21, 2006; revised manuscript received May 10, 2007, accepted May 15, 2007.

* Reprint requests and correspondence: Dr. Iacopo Olivotto, Cardiologia San Luca, Azienda Ospedaliera Universitaria Careggi, Viale Pieraccini 17, 50132, Florence, Italy. (Email: olivottoi{at}ao-careggi.toscana.it).

Dynamic left ventricular outflow tract obstruction is an important pathophysiologic feature of hypertrophic cardiomyopathy (HCM) and a predictor of clinical deterioration and cardiovascular mortality. Patients with marked obstruction and severe limiting symptoms refractory to maximum medical management are considered candidates for invasive septal reduction therapy, which includes surgical myectomy and alcohol septal ablation (ASA). Availability of both surgical myectomy and ASA has polarized the cardiovascular community concerning the most appropriate implementation of these two interventions. The ensuing controversy of whether myectomy and ASA are truly equivalent options has resulted in calls for a prospective randomized trial. However, upon analysis, such a myectomy versus ASA trial, adequately powered to compare the key issue of long-term outcome, poses a myriad of practical problems that seem virtually insurmountable. Therefore, it is appropriate to revisit this evolving debate at this time, identify the unique obstacles to a randomized study design, and achieve some clarity concerning the most realistic clinical strategies for symptomatic patients with HCM and outflow obstruction.

Abbreviations and Acronyms
  ASA = alcohol septal ablation
  CABG = coronary artery bypass graft surgery
  HCM = hypertrophic cardiomyopathy
  LV = left ventricular
  PTCA = percutaneous transluminal coronary angioplasty
  SAM = systolic anterior motion




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S R Ommen, P M Shah, and A J Tajik
Left ventricular outflow tract obstruction in hypertrophic cardiomyopathy: past, present and future
Heart, October 1, 2008; 94(10): 1276 - 1281.
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