Alternative Approaches for Alcohol Septal Ablation in Hypertrophic Cardiomyopathy: The Call for a Personalized Treatment

Hypertrophic cardiomyopathy (HCM) is a relatively common genetic condition characterized by increased thickness of the left ventricular wall1,2. The presence of left ventricular outflow tract (LVOT) obstruction is a defining feature of HCM and constitutes a key element in both the diagnosis and the management of the disease3. LVOT obstruction in HCM is primarily attributed to the systolic anterior movement (SAM) of elongated mitral valve leaflets, which come into contact with the septum at the subaortic level. The diagnosis of obstruction is typically made by echocardiography and is defined by the presence of a peak LVOT gradient ≥ 30 mm Hg, measured using continuous-wave Doppler, either at rest or after the Valsalva maneuver. LVOT obstruction occurs at rest in approximately 35% of patients with HCM, while dynamic obstruction can be provoked during the Valsalva maneuver or exercise in around 30% of cases. Septal reduction therapy has demonstrated clear efficacy in reducing LVOT obstruction and should be considered for HCM patients with an LVOT gradient > 50 mm Hg, moderate to severe symptoms, and/or exertional syncope despite maximally tolerated medical therapy4. Septal reduction can be achieved through either surgical myectomy or a percutaneous intervention.