Approach to treatment selection for hypertrophic cardiomyopathy

James Januzzi, MD: Give us some information on the most important factors to consider when choosing one therapy over another.

Steve R. Ommen, MD: The #1 thing is the other atypical patient anatomy. The surgeon has more degrees of freedom with what they can treat when caring for someone compared to catheter therapy, which depends not only on muscle anatomy but also arterial anatomy. Sometimes they don’t fit well, where the surgeon can tailor the approach to the anatomy. Are the tract muscles also hypertrophied? Is the mitral valve too long? Are there any other issues? If there’s another structural heart disease, then you’re going to lean a lot more towards surgery. Likewise, the thicker the heart and the higher the gradient, the surgeon can achieve a more robust result than a catheter-based procedure. Then there is the question of what local expertise is available.

James Januzzi, MD: Absolutely. Institutional expertise is so important. Marty, what do you think?

Martin S. Maron, MD: No question. One of the big points is the procedural experience, more with surgery than with alcohol ablation, to get the awesome results that Steve just talked about for surgery. In fact, I tell patients that there are perhaps few, if any, other procedures that we perform on patients in general medicine, not just cardiology, that have such dramatic improvement before compared to after. That’s because it’s a mechanical form of heart failure and you relieve it in an otherwise intact ventricle. This is the reason why patients get such a huge benefit. But for this advantage, the operation must be performed by experienced hands, otherwise these operative risks – morbidity, mortality – are much higher.

James Januzzi, MD: It’s really helpful.

Javed Butler, MD, MPH, MBA: With alcohol septal ablation, you don’t have to know any acute metrics, so how many times do you have to go back because you haven’t done enough?

Martin S. Maron, MD: That was the other point about alcohol ablation versus surgery, is the repeat rate of the procedure, which is higher for alcohol ablation than for surgery. Steve said about 2% for surgery, which is correct, and alcohol ablation is about 10%.

James Januzzi, MD: And it takes time to know if it’s successful.

Martin S. Maron, MD: It’s true, and those 2 things are important in the conversation you have with patients who are candidates for both.

Steve R. Ommen, MD: Part of this conversation is that for ablation, the hospital stay will be shorter, the pain will be less, and the return to work or activity will be shorter. If all else is equal, patients have the option to choose based on a thorough discussion of the risks and benefits of both.

James Januzzi, MD: This is really helpful and brings us to our next topic. This has been a great discussion on contemporary treatments. This gives us the opportunity to move on to new mechanisms of action and treatments that are currently being investigated in HCM [hypertrophic cardiomyopathy]and maybe some preliminary data.

Transcript edited for clarity

Martin E. Berry