Letter From the Guest Editor: Operative Management of Hypertrophic Obstructive Cardiomyopathy—Gold Standard Septal Myectomy to Stand the Test of Time

Welcome to the latest CTSNet Guest Editor Series, "Operative Management of Hypertrophic Obstructive Cardiomyopathy—Gold Standard Septal Myectomy to Stand the Test of Time." This time, Eduard Quintana, MD, PhD, FECTS, serves as our Guest Editor. We asked him to bring together videos that teach us more on hypertrophic obstructive cardiomyopathy. Learn more about Dr. Quintana by reading his Featured Profile interview.

• There are eight contributor videos in this series. The eight videos were released between April 4 and April 7, 2022, with two videos released per day. For the video titles and order, please see the bottom of the page.
• On Friday, April 8, at 8:00 a.m. Central (US), CTSNet hosted Dr. Quintana and some of his contributors for a live discussion to culminate this series. 

Click Here to Watch Webinar Recording

Dear CTSNet Reader,

Six decades have passed since the initial recognition of a complex disease and pioneering operations aimed at obstruction relief in patients with hypertrophic cardiomyopathy. Morrow and Brockenbrough in 1961 (1) described transaortic septal myectomy. Just a few months later, Kirklin and Ellis (2) reported on successful transventricular resection. Altogether, they set the path to treat patients with heart failure due to intracavitary obstruction. 

A previously perceived disease with dismal prognosis has been transformed, through collaborative multidisciplinary work, into a condition with excellent quality of life and survival. Open heart operations represent a significant part of the puzzle that allows to change disease course (3). 

In expert centers, surgery for hypertrophic obstructive cardiomyopathy is a one-time, low-risk (<0.5–1%), and potentially life-changing operation (4). Septal myectomy is responsible for resolution of advanced symptoms because of abolition of left ventricular outflow tract impedance and secondary mitral regurgitation. However, it requires a deep understanding of all features leading to obstructive physiology, a steep learning curve, and significant skill.  

To date, surgery remains the gold standard septal reduction therapy for severely symptomatic patients and can result in a long-term restoration to normal (or greatly improved) quality of life and potentially impact longevity (7,8). The safety and efficacy of myectomy in experienced hands has inherently led to expand the indications for the less symptomatic (5,6). 

We have summoned some distinguished colleagues to share their knowledge, techniques, and insight. Two world-recognized cardiologist colleagues have prepared lectures in which we will dive into the contemporary role of myectomy and improve the understanding of disease pathophysiology with imaging. A group of surgeons with established expertise in HCM will provide tools to approach these complex operations.  

A comprehensive 3D left ventricular anatomic model providing insight on how the septal resection of this operation is carried out is the technical starting point of this series. This follows with a lecture on classic extended septal myectomy and insights into options for patients frequently presenting with concomitant atrial fibrillation. A couple more lectures will focus on adjunct left ventricular outflow tract and mitral interventions that could be useful in some patients to provide full resolution of obstruction while preserving native mitral valve competence. Another lecture is dedicated to patients with HCM and myocardial bridging. This will offer insight into potential indications to surgically address this less frequent feature and provide technical guidance. To round it all up, we have called upon a group of enthusiastic colleagues who have led and participated in the development of new myectomy programs to share their experiences. 

It is our hope that, all along, this special series positively impacts the care of patients with obstructive hypertrophic cardiomyopathy worldwide through your practices.  

Eduard Quintana, MD, PhD, FECTS
Hospital Clínic de Barcelona
University of Barcelona Medical School

Guest Editor Series Contributor Videos:

1. Myectomy: A Cardiologist’s Perspective by Martin Maron
2. Imaging in Obstructive Hypertrophic Cardiomyopathy by Milind Desai
3. Septal 3D Anatomy to Guide a Septal Myectomy by Nicholas Smedira
4. Surgical Management of Atrial Fibrillation in Patients Undergoing Myectomy for Obstructive Hypertrophic Cardiomyopathy by Hartzell V. Schaff, Sri Harasha Patlolla, Joseph A. Dearani
5. Modified Morroq Septal Myectomy Associated with a Transaortic Mitral Edge-to-Edge Suture for an Obstructive HCM by Jean- Francois Obadia, Danial Grinberg

6. Unroofing of Myocardial Bridging Combined with Septal Myectomy in Hypertrophic Cardiomyopathy: When and How? by Sameh M. Said, Gamal Marey

7. Septal Myectomy and Concomitant Left Ventricular Outflow Tract Intervention for Obstructive Hypertrophic Cardiomyopathy by Eduard Quintana

8. HOCM Roundtable: How to Start and Develop a Program by Patrick Myers, Carlos Mestres, Pietro Bajona, Juan Grau, Cristins Ibanez

Letter References: 

1. Morrow AG, Brockenbrough EC. Surgical treatment of idiopathic hypertrophic subaortic stenosis: technic and hemo-dynamic results of subaortic ventriculomyotomy. Ann Surg 1961; 154: 181–189. 
2. Kirklin JW, Ellis FH. Surgical relief of diffuse subvalvular aortic stenosis. Circulation 1961; 24: 739–742.  
3. Maron BJ, Desai MY, Nishimura RA et al. Management of hypertrophic cardiomyopathy. J Am Coll Cardol. 2022. 79:390-414. 
4. Maron, BJ, Dearani JA, Omen SR et al. Low operative mortality achieved with surgical septal myectomy: role of dedicated hypertrophic obstructive cardiomyopathy centers in the management of dynamic subaortic obstruction. J Am Coll Cardiol. 2015;66:1307-1308. 
5. Alashi A, Smedira NG, Hodges K, et al. Outcomes in guideline-based class I indication versus earlier referral for surgical myectomy in hypertrophic obstructive cardiomyop- athy. J Am Heart Assoc 2021; 10: e016210.  
6. Meghji Z, Nguyen A, Benish F et al. Survival differences in women and men after septal myectomy for obstructive hypertrophic cardiomyopathy. JAMA Cardiol. 2019;4(3):237-245 
7. Alashi A, Smedira NG, Hodges K et al. Outcomes in guideline-based class I indication versus earlier referral for surgical myectomy in hypertrophic obstructive cardiomyopathy. J Am Heart Assoc. 2021;10:e016210 
8. Ommen SR, Mital S, Burke MA et al. 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy. A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2020;76:e159-e240.