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(Circulation. 1999;100:e99.)
© 1999 American Heart Association, Inc.

Circulation Electronic Pages

Pitfalls in Clinical Recognition and a Novel Operative Approach for Hypertrophic Cardiomyopathy With Severe Outflow Obstruction Due to Anomalous Papillary Muscle

Ulrich Sigwart, MD, FRCP, FACC, FESC

Department of Invasive Cardiology Royal Brompton and Harefield NHS Trust, London, UK

	Introduction

 
To the Editor:

The Brief Rapid Communication by Maron et al¹ describing in greater detail a variant of hypertrophic obstructive cardiomyopathy significantly adds to our knowledge of this intriguing disease.

The point is very well taken: hypertrophic obstructive cardiomyopathy is not one single entity! Every case has its very own problems, and there are hardly 2 cases alike.

In their discussion, the authors raise the important question of whether nonsurgical techniques^{2 3 4} could possibly deal with this particular variant. Certainly, from their surgical illustrations, it appears as if transluminal techniques could be considered in this situation. All myocardium is supplied by coronary arteries, and if the supply arteries of the myectomy territory can be properly identified, it should be possible to deal with this problem by transluminal myocardial reduction with alcohol.

A number of cases of midventricular obstruction have now been successfully dealt with by nonsurgical myocardial reduction.⁵ In the cases presented by Maron et al,¹ it is conceivable that such a procedure would be as effective or almost as effective as surgery.

It would be most helpful to see the coronary angiogram performed before surgery in these 2 patients, but it is normally possible to cannulate the supply arteries in these cases. The issue that remains unresolved, however, is how much the papillary muscle itself contributes to the outflow tract gradient, because it is unlikely that this could be modified by nonsurgical techniques.

	References

 
1. Maron BJ, Nishimura RA, Danielson GK. Pitfalls in clinical recognition and a novel operative approach for hypertrophic cardiomyopathy with severe outflow obstruction due to anomalous papillary muscle. Circulation. 1998;98:2505–2508.[Abstract/Free Full Text]

2. Sigwart U. Nonsurgical myocardial reduction for hypertrophic obstructive cardiomyopathy. Lancet. 1995;346:211–214.[Medline] [Order article via Infotrieve]

3. Knight C, Kurbaan AS, Seggewiss H, Henein M, Gunning M, Harrington D, Fassbender D, Gleichmann U, Sigwart U. Nonsurgical septal reduction for hypertrophic obstructive cardiomyopathy: outcome in the first series of patients. Circulation. 1997;95:2075–2081.[Abstract/Free Full Text]

4. Seggewiss H, Faber L, Kurbaan A, Sigwart U. Percutaneous transluminal septal myocardial ablation for hypertrophic obstructive cardiomyopathy. In: Topol EJ, ed. Textbook of Interventional Cardiology. 3rd ed. Philadelphia, Pa: WB Saunders; 1999;47:878–886.

5. Brookes C, Stables R, Sigwart U. Massive septal hypertrophy with no outflow tract gradient: an indication for alcohol ablation? 2nd European Workshop on Hypertrophic Obstructive Cardiomyopathy. Bad Oeynhausen, Germany, October 30, 1998. Abstract.

Response

Barry J. Maron, MD

Minneapolis Heart Institute Foundation Minneapolis, Minn

Rick A. Nishimura, MD; Gordon K. Danielson, MD

Mayo Clinic, Rochester, Minn

	Introduction

 

We appreciate Dr Sigwart’s interest in our observations regarding the surgical management of obstructive hypertrophic cardiomyopathy (HCM) . . . [Full Text of this Article]