Key result
Septal myectomy relieves HCM obstruction by geometrically reshaping the ventricle and mitral-septal relationships.
Why the study?
Although LVOTO in HCM has traditionally been attributed to septal hypertrophy, septal thickness correlates inconsistently with obstruction severity, and cardiac myosin inhibitors can reduce or eliminate LVOTO without septal resection, prompting a reappraisal of its pathophysiology and surgical implications.
Answers are grounded in this paper and cite their sources.
Dynamic left ventricular outflow tract obstruction in hypertrophic cardiomyopathy arises from an interplay of ventricular geometry, the mitral-subvalvular apparatus, septal morphology, and contractile state, redefining septal myectomy as a geometric intervention rather than just a debulking procedure.
Background For more than half a century, left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy (HCM) has been understood primarily as a consequence of septal hypertrophy. However, the correlation between septal thickness and obstruction severity is inconsistent, and cardiac myosin inhibitors can markedly reduce, and in many patients eliminate, LVOTO without septal resection. Aim To reappraise the pathophysiology of dynamic LVOTO and its implications for surgical strategy. Methods We performed a narrative review of PubMed, MEDLINE, and Scopus (1990–2026), informed by our institutional experience with minimally invasive septal myectomy in over 1000 HCM patients (unpublished institutional data). Results Obstruction is best understood as a dynamic phenomenon arising from the interaction of four factors: ventricular geometry, the mitral and subvalvular apparatus, septal morphology, and contractile state. Septal thickness is one contributor among several rather than the dominant driver. Myosin inhibitors target the contractile component; surgery modifies geometry and mitral–septal relationships. A subset of patients requires adjunctive mitral–subvalvular procedures beyond isolated septal resection. Conclusions Septal myectomy is being redefined as a geometric intervention rather than a debulking procedure. Understanding the relative contribution of each mechanistic component can guide patient‐specific matching of surgical and medical therapies.
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Cui et al. (2026) conducted a review in Hypertrophic cardiomyopathy with dynamic left ventricular outflow tract obstruction. Septal myectomy and cardiac myosin inhibitors was evaluated. Septal myectomy (>1,000 HCM cases) acts as a geometric intervention modifying ventricular geometry and mitral-septal relationships across 4 mechanistic factors of outflow obstruction.
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