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Myectomy vs ASA in Obstructive HCM — EECC MCQ

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ModerateCardiomyopathyMyectomy vs ASA in Obstructive HCMEECC

A 45-year-old man with obstructive HCM (resting LVOT gradient 65 mmHg, maximum wall thickness 22 mm) has severe symptoms (NYHA III) despite maximally tolerated disopyramide and bisoprolol. His anatomy is suitable for both septal myectomy and alcohol septal ablation (ASA). What factors favour surgical myectomy over ASA?

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Correct answer: B — Concomitant cardiac pathology requiring surgery (e.g. MV repair), younger age, and availability of an experienced surgical centre

Both septal myectomy and alcohol septal ablation (ASA) are effective for obstructive HCM refractory to medical therapy. The 2023 ESC Cardiomyopathy Guidelines recommend myectomy as the preferred option (Class I, LOE B) at experienced centres, particularly when: (1) concomitant cardiac pathology needs surgical correction (e.g. mitral valve repair, papillary muscle abnormalities, myocardial bridges); (2) younger patients (myectomy has more durable long-term data and avoids the septal scar from ASA which may be pro-arrhythmic); (3) septal anatomy is unfavourable for ASA (e.g. no suitable septal perforator). ASA is a reasonable alternative (Class IIa) when surgery is high-risk, the patient declines surgery, or surgical expertise is unavailable.

Reference: ESC (2023): Guidelines on Cardiomyopathies