Management of symptomatic hypertrophic cardiomyopathy: pills, alcohol, or the scalpel?

The article published in Revista Española de Cardiologı́a describing the 10-year follow-up after alcohol septal ablation (ASA) in patients with hypertrophic obstructive cardiomyopathy (HOCM) is a welcome addition to the literature. Although the series reflects an earlier experience with a technique that continues to evolve over time, the encouraging long-term outcomes bode well for the next generation of patients who will undergo ASA after what we would hope is an adequate trial of medical therapy. The numbers of patients in this reported experience from 5 centers is small, as are the numbers undergoing surgical myectomy. It would have been of interest to know whether the use of septal reduction therapy increased over time. In addition, it would have been interesting to know whether the surgical myectomy population differed from those undergoing ASA or whether the decision was made on the basis of institutional expertise and facilities. The authors clearly state in their discussion that the results of either septal myectomy or ASA depend on operator experience, as well as an understanding of the disease itself. We and others have shown that the success and complications rate of ASA significantly improve after a procedural volume of > 50 patients. Thus, it would be expected that the long-term results of ASA in Spain will become even better as centers gain greater experience. There is a balance between a higher volume of alcohol used in the procedure producing better hemodynamic results and the possible long-term detrimental consequences of adverse myocardial remodeling and ventricular arrhythmias. The mean of 3.7 mL of alcohol used in the study herein discussed is larger than the 1.5 to 2.0 mL used by more experienced centers and may account for the need for transplant and implantable cardioverter-defibrillators (ICD) in the patient cohort. The selection of smaller branches of septal perforator arteries that directly target the region of systolic anterior motion with septal contact using echographic contrast injections allows for smaller volumes of alcohol while maintaining the optimal hemodynamic results. Other changes in technique,