Surgical septal myectomy is the preferred treatment strategy in hypertrophic cardiomyopathy (HC) to reverse progressive heart failure symptoms due to left ventricular outflow obstruction. However, open-heart surgery and the ventricular septal myectomy option in particular have limited accessibility in many parts of the world, including developing countries such as India, where skilled surgeons familiar with the complex left ventricular outflow tract anatomy of obstructive HC are rare. Indeed, septal myectomy, which is currently performed in only a limited number of countries, can become available in other venues if experienced surgeons dedicate their skills to this highly specialized but rewarding operation. Relevant to this issue, we describe a recent myectomy initiative in India (New Delhi) that demonstrates the possibility of generating a surgical myectomy program outside of an elite academic center environment, otherwise regarded as unfavorable for such an initiative. Demonstration that safe and effective septal myectomy is possible under such difficult circumstances bodes well for the expansion of this operation to many countries in the best interests of the hypertrophic cardiomyopathy patient population.
Hypertrophic cardiomyopathy (HC) is a genetic heart disease estimated to affect many thousands (if not millions) of patients throughout the world that can be treated with a variety of effective management options. Progressive and limiting heart failure symptoms due to left ventricular (LV) outflow tract obstruction are reversible with septal myectomy, a surgical procedure that abolishes the subaortic gradient and normalizes LV intraventricular pressures, thereby returning the vast majority of patients to normal levels of activity and good quality of life.
Myectomy is established as the preferred treatment option for severely symptomatic drug refractory patients with obstructive HC, based on guideline and consensus panel recommendations from all relevant societies in the United States and Europe. For almost 50 years, myectomy has been performed effectively in patients with obstructive HC, largely in experienced and dedicated centers in the United States and Canada, where it now has a particularly low operative mortality (<0.5%).
However, over the last 15 years, there has been considerable enthusiasm in many areas of the world for alcohol septal ablation, a percutaneous technique heavily promoted by the interventional cardiology community. Alcohol ablation has been advanced as an alternative option to myectomy for severely symptomatic patients with obstructive HC, largely patients of advanced age with important co-morbidities, or with personal adversity to open-heart surgery. This technique has the potential advantage of accessibility to those patients geographically removed from experienced and dedicated myectomy centers and surgeons.
Nevertheless, myectomy and alcohol ablation cannot be regarded as similar or interchangeable treatment options for relieving outflow obstruction. Indeed, there is a persistent and growing concern regarding the arrhythmia risk associated with the alcohol-induced transmural septal infarction produced by alcohol ablation. Furthermore, there is increasing evidence that abnormalities of the mitral valve apparatus play an important role in systolic anterior motion of the mitral valve and LV outflow obstruction in HC. The localized septal thinning produced by alcohol ablation is often insufficient to abolish the outflow gradient and relieve symptoms in those many patients with HC in whom abnormalities of the mitral valve apparatus play an important role in subaortic obstruction.
Therefore, although myectomy is considered the preferred (“gold standard”) consensus treatment for severely symptomatic patients with obstructive hypertrophic cardiomyopathy, the need for experienced myectomy surgeons far exceeds those available at this time, particularly in developing countries where hypertrophic cardiomyopathy (and myectomy) have not been health care priorities. This gap represents a major unmet need in the management of hypertrophic cardiomyopathy.
Most patients with hypertrophic cardiomyopathy live in the most populous countries of India and China, where there has been little prior awareness regarding the importance of surgical myectomy. Instead, in such developing societies, management of symptomatic patients with LV outflow obstruction in this disease has been virtually confined to medical therapy and percutaneous alcohol septal ablation.
Therefore, when we encounter evidence that the septal myectomy operation can be performed safely and effectively outside of North American and European centers in environments that could be considered inhospitable for such a highly specialized procedure, it seems sufficiently noteworthy and meritorious to report here in some detail.
This, then, is the story of Dr. Sujay Shad, Senior Consultant Cardiac Surgeon, of Sir Ganga Ram Hospital in New Delhi, India, a postgraduate teaching and training center ( Figure 1 ). In July 2010, Dr. Shad identified the surgical septal myectomy as an unmet need for patients with obstructive hypertrophic cardiomyopathy in Northern India ( Figure 2 ) and began to address that deficiency by establishing a new myectomy program at his hospital. Over the past 5 years, he has performed the extended septal myectomy operation successfully in 29 severely symptomatic patients (mean age 42 years; range 11 to 66; 70% men) resulting in substantial relief of the outflow gradient from a preoperative average peak of 123 to 12 mm Hg postoperatively. Severe heart failure symptoms were abolished in all patients and reduced to New York Heart Association class I (87%) and class II (13%) and, importantly, with zero operative mortality.
