In hypertrophic obstructive cardiomyopathy (HOCM) with persistent symptoms (NYHA class III) and LVOT gradient ≥ 50 mmHg despite maximally tolerated beta-blocker and disopyramide, which intervention is preferred in an anatomically eligible patient with severe septal hypertrophy?

• A Alcohol septal ablation
• B Cardiac resynchronisation therapy
• C Implantable cardioverter-defibrillator placement
• D Surgical septal myectomy (Morrow procedure) ✓

Explanation

Current ACC/AHA 2020 HCM guidelines recommend surgical septal myectomy (Morrow procedure) as the gold standard for eligible patients with drug-refractory symptomatic HOCM and LVOT gradient ≥ 50 mmHg, particularly at experienced HCM centres where operative mortality is < 1%. Myectomy provides durable relief of obstruction and superior long-term outcomes. Alcohol septal ablation (ASA) is an alternative for patients who are high surgical risk, elderly, or who prefer it — but is not preferred over myectomy in anatomically eligible patients with severe septal hypertrophy. ICD is for SCD prevention, not symptom relief. CRT has no role in HOCM.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.