What is the next step in managing a 50-year-old female with exertional dyspnea, chest pain, and presyncope, who has a harsh systolic ejection murmur, asymmetric septal hypertrophy, and left ventricular outflow tract obstruction with a gradient of 54 mmHg, unresponsive to Beta Blockers (BB) or Beta-Adrenergic Blocking Agents (BCC)?

From the Guidelines

The next step in management for this 50-year-old woman with hypertrophic obstructive cardiomyopathy (HOCM) is surgical myectomy, as recommended by the 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy 1. This patient presents with classic symptoms of HOCM including exertional dyspnea, chest pain, and pre-syncope, along with a harsh systolic ejection murmur that increases with passive leg elevation. The echocardiogram confirms asymmetric septal hypertrophy with left ventricular outflow tract obstruction and a significant gradient of 54 mmHg. Since she has failed medical therapy with beta-blockers, invasive treatment is indicated. Surgical myectomy is considered the preferred treatment for most patients who meet these criteria, especially considering the patient's age and the presence of significant outflow tract obstruction 1. Some key points to consider in the management of this patient include:

• The patient's symptoms are refractory to optimal medical therapy, making invasive treatment necessary.
• The presence of a significant outflow tract gradient, which is a key indicator for surgical intervention.
• The importance of shared decision-making between the patient and the healthcare team to determine the best course of treatment.
• The potential benefits and risks of surgical myectomy, including the potential for symptom relief and the risks of complications such as complete heart block or ventricular septal perforation.
• The role of other treatment options, such as percutaneous septal ablation, which may be considered in patients who are not candidates for surgical myectomy or who have a high risk of surgical complications 1. It is also important to consider the patient's overall health status, including the presence of any comorbidities, and to involve a multidisciplinary team of healthcare professionals in the decision-making process 1. Ultimately, the goal of treatment is to relieve symptoms, improve quality of life, and reduce the risk of complications, while also taking into account the patient's individual preferences and values.

From the Research

Management of Hypertrophic Obstructive Cardiomyopathy

The patient's symptoms and medical history suggest hypertrophic obstructive cardiomyopathy (HOCM) with left ventricular outflow tract (LVOT) obstruction. The next step in management would be to consider septal reduction therapy, as the patient is unresponsive to beta blockers or beta-adrenergic blocking agents (BCC) 2.

Septal Reduction Therapy

Septal reduction therapy includes septal myectomy and alcohol septal ablation (ASA). ASA is a minimally invasive procedure that involves the selective infusion of high-grade alcohol into a septal branch supplying the basal interventricular septum to create an iatrogenic infarction, reducing LVOT obstruction 3, 4, 5, 6.

Patient Selection for ASA

Patient selection for ASA is crucial, and the procedure should be performed in experienced centers with comprehensive programs 5, 6. The selection of candidates must be rigorous, and the procedure is indicated in symptomatic patients resistant to optimal medical treatment with a left intraventricular gradient equal to or higher than 50 mmHg, spontaneous or with exercise 4.

Benefits and Risks of ASA

The benefits of ASA are comparable to those seen with surgical myectomy in terms of functional class, exercise capacity, and gradient regression 4. However, the procedure carries risks, including complete atrioventricular block requiring the implantation of a definitive pacemaker, which is the most common complication 4, 5.

Key Considerations

• ASA is an effective treatment for symptomatic patients with HOCM, obtaining a marked decrease in LVOT pressure gradient and symptomatic improvement 3.
• The procedure should be performed in experienced centers with comprehensive programs 5, 6.
• Patient selection is crucial, and the procedure is indicated in symptomatic patients resistant to optimal medical treatment with a left intraventricular gradient equal to or higher than 50 mmHg, spontaneous or with exercise 4.
• The benefits and risks of ASA should be discussed with the patient, and a balanced decision should be made regarding the procedure 2.

Some key points to consider in the management of this patient include:

• The patient's age and comorbidities should be taken into account when deciding between septal myectomy and ASA 2, 5.
• The patient's symptoms and medical history should be carefully evaluated to determine the best course of treatment 2.
• The procedure should be performed by experienced operators in institutions with multidisciplinary HCM programs 2.