With great interest, I have read the article “Golden Jubilee of Hypertrophic Cardiomyopathy: Is Alcohol Septal Ablation the Gold Standard?” by Parakh and Bhargava . Fourteen years after the first publication of three patients treated by alcohol septal ablation (ASA) and after the first patient undergoing the ASA procedure in our hospital in the same year, more than 1000 patients have been treated in our institution . Accordingly, I agree with the authors’ conclusion that “the pendulum of gold standard may have started swinging away from surgical myectomy towards ASA.” I believe it is justified that, today in all experienced centers and adult patients with a very advanced stage of common hypertrophic obstructive cardiomyopathy (HOCM), ASA has become the therapeutic option of choice. It is no longer only an “additional approach and an alternative to surgery” as was stated in the expert consensus document published 6 years ago . I believe the main reason for such a conclusion is that all clinical data including survival ones were proved to be favorable, consistent, and ongoing, and compare well with the outcome after surgery of HOCM . Maron , however, who unfortunately is no interventional cardiologist and is not able to perform ASA in his institution, is the only one I know who, from the early beginning, goes on in the literature with a critical view, but also with emotional ideas, against ASA in favor of surgery.

However, I do not agree with the authors’ description of the history of ASA. The reason is that this chapter of the review article only reflects “half the historical truth” and is not based on correct historical facts regarding the introduction of ASA by Sigwart in 1995. It is based on “post hoc” statements by him, which means they were delivered after our correspondence on the first three cases including that of a 14-year-old child.

What are the historical facts? With regard to studies before the first therapeutic application of ASA, the authors state, “Sigwart and the late Dr. Grbic found significant reduction in left ventricular outflow tract gradient when angioplasty balloon was inflated in the first septal artery” . This, however, is not true. Years ago, when we checked the corresponding articles which, for the first time, were cited in 1997 2 years after the Lancet article , nothing was mentioned or written about any investigation of HOCM or septal artery occlusion in HOCM. Both articles dealt with coronary artery disease, not with HOCM. Correspondingly, in the response letter, Sigwart was not talking about any published investigations but rather about the problem of “intellectual property” and of “prior art” . ASA, however, means more. It means to inject absolute ethanol into the heart vessel of a patient with the consequence of creating a myocardial infarction by a physician. It also means that, in performing the first procedure, one needs a careful, systematic study; no precipitate acting; and a critical selection of the first patients. In consideration of that we did such a study . For ethical reasons, we started with ASA in patients with severe comorbidity in whom surgical treatment was at least relatively contraindicated . Indeed, the only systematic and published study (started in 1991) in the literature to develop the concept of catheter-based treatment with ASA has been performed by our group . It was first presented at the Annual Congress of the German Cardiac Society in April 1994 , 2 months before Sigwart used this concept and treated the first patient. It included the suggestion to use the common PTCA technique and to select the first septal branch of the LAD. We also suggested to inject absolute alcohol for the first clinical application of the concept. Sigwart did not comment in the Lancet article as to why he used alcohol. I came up with the idea of a catheter-based therapy by HOCM using the PTCA technique already years ago and put it on a list of other ideas. The suggestion to use alcohol was derived from an article by Brugada et al. dealing with the treatment of rhythm disorders by transcoronary alcohol injection, including the animal experiments of Inoue . The Brugada et al. article encouraged me to start with the fundamental studies in 1991 . Recently, the author told me that he also had the idea to develop the same concept and he showed me the corresponding brief protocol. However, his former chief, Professor Wellens, refused the idea.

Sigwart stated in the response letter that the very first alcohol ablation in HOCM was performed by him before the publication of our abstract. This is not right either, because it was presented in April 1994, whereas his first case was treated by ASA in June 1994 . Sigwart, being German and a member of the German Cardiac Society who also worked for many years at Heart Center Bad Oynhausen which is very near to our center, has known the publication of the abstract and put it on the reference list of the Lancet article , but without any comment or appreciation that it contained the underlying study of his first catheter-based treatment of HOCM.