Approaching Treatment Selection for Hypertrophic Cardiomyopathy

James Januzzi, MD: Give us some insights about the most important factors to consider when you’re choosing one therapy vs another.

Steve R. Ommen, MD: The No. 1 thing is the patients’ other atypical anatomy. The surgeon has more degrees of freedom with what they can treat when they’re taking care of someone vs a catheter-based therapy, which is beholden not only to the muscular anatomy but to the arterial anatomy. Sometimes they don’t match up right, where the surgeon can tailor the approach to the anatomy. Are the pathway muscles also hypertrophied? Is the mitral valve too long? Are there other issues? If there’s other structural cardiac disease, then you’re going to lean a lot more toward surgery. Similarly, the thicker the heart and the higher the gradient, the surgeon can get a more robust result than a catheter-based procedure. Then there are issues of what local expertise is available.

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

Martin S. Maron, MD: No question. One of the important points is procedural experience, more so with surgery than alcohol ablation, to get the impressive results that Steve just was talking about for surgery. In fact, I tell patients that there may be few, if any, other procedures that we do on patients in medicine overall, not just cardiology, that have such a dramatic improvement before vs after. That’s because it’s a mechanical form of heart failure and you’re relieving that in an otherwise intact ventricle. That’s the reason the patients get such a huge benefit. But for that benefit, the operation has to be done in experienced hands, or else those operative risks—morbidity, mortality—are much higher.

James Januzzi, MD: That’s really helpful.

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

Martin S. Maron, MD: That was the other point about alcohol ablation vs surgery, is the repeat procedure rate, which is higher for alcohol ablation than it is for surgery. Steve said 2% or so for surgery, which is right, and alcohol ablation is about 10%.

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

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

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

James Januzzi, MD: That’s really helpful, and leads us to our next topic. This has been a great discussion about the contemporary treatments. It gives us an opportunity to move on to newer mechanisms of action and treatments that are currently under investigation in HCM [hypertrophic cardiomyopathy], and maybe some preliminary data.

Transcript Edited for Clarity