When is surgery needed for anabolic steroid-induced hypertrophic cardiomyopathy?

From the Guidelines

Surgery is typically needed for anabolic steroid-induced hypertrophic cardiomyopathy when patients experience severe symptoms that don't respond to medication and lifestyle changes, or when there are significant structural abnormalities causing life-threatening complications, such as severe left ventricular outflow tract obstruction (gradient >50 mmHg) with persistent symptoms despite maximal medical therapy, as recommended by the 2011 ACCF/AHA guideline 1.

Key Indications for Surgery

• Severe left ventricular outflow tract obstruction (gradient >50 mmHg) with persistent symptoms despite maximal medical therapy
• Recurrent syncope
• Refractory heart failure
• Life-threatening arrhythmias

Surgical Procedures

• Septal myectomy: removes part of the thickened heart muscle to improve blood flow, considered the preferred treatment for most patients who meet the core selection criteria 1
• Alcohol septal ablation: may be considered for high-risk surgical candidates, with a higher risk of abnormal atrioventricular conduction requiring permanent pacing compared to surgical myectomy 1

Pre-Surgical Evaluation

• Comprehensive evaluation including echocardiography, cardiac MRI, and sometimes cardiac catheterization to assess the severity and specific anatomical features of the condition
• Patients must discontinue steroid use completely before considering surgery

Medical Management

• Beta-blockers (like metoprolol 25-200 mg daily) or calcium channel blockers (like verapamil 120-480 mg daily) to control symptoms before considering surgery 1

From the Research

Indications for Surgery

Surgery is typically considered for patients with anabolic steroid-induced hypertrophic cardiomyopathy who have:

• Severe obstruction or symptoms refractory to medical therapy 2
• Dynamic left ventricular outflow tract obstruction and symptoms of dyspnea, angina, and syncope 3
• Hypertrophic obstructive cardiomyopathy that cannot be controlled by medical therapy 4

Surgical Options

The following surgical options are available:

• Septal myectomy: a surgical procedure that involves removing a portion of the thickened septum to relieve obstruction 3, 5
• Alcohol septal ablation: a less invasive procedure that involves injecting alcohol into the septal perforator artery to reduce the thickness of the septum 3, 5
• Mitral valve replacement: a surgical procedure that involves replacing the mitral valve to correct another mechanism of obstruction 4, 6

Selection of Patients for Surgery

Patients are selected for surgery based on the following criteria:

• Severity of symptoms and obstruction 5
• Response to medical therapy 2, 3
• Presence of co-morbid conditions that may increase the risk of surgery 5
• Patient preference and availability of experienced operators and institutions 3

Outcomes of Surgery

The outcomes of surgery for hypertrophic cardiomyopathy are generally favorable, with:

• Relief of obstruction and improvement in symptoms 3, 4
• Low morbidity and mortality rates for septal myectomy 5
• Higher mortality rates and need for permanent pacemaker for alcohol septal ablation 5