AHA GUIDELINES Bundle (free trial)

29 8.1.2. Invasive Treatment of Symptomatic Patients With Obstructive HCM COR LOE Recommendations 1 B-NR 1. In patients with obstructive HCM who remain symptomatic despite GDMT, SRT in eligible patients,* performed at experienced HCM centers, † is recommended for relieving LVOTO (Table 3, Table 4). 1 B-NR 2. In symptomatic patients with obstructive HCM who have associated cardiac disease requiring surgical treatment (eg, associated anomalous papillary muscle, markedly elongated anterior mitral leaflet, intrinsic mitral valve disease, multivessel CAD, valvular aortic stenosis), surgical myectomy, performed at experienced HCM centers, † is recommended (Table 3, Table 4). 1 C-LD 3. In adult patients with obstructive HCM who remain severely symptomatic, despite GDMT and in whom surgery is contraindicated or the risk is considered unacceptable because of serious comorbidities or advanced age, alcohol septal ablation in eligible patients,* performed at experienced HCM centers, † is recommended (Table 3, Table 4). 2b B-NR 4. In patients with obstructive HCM, earlier (NYHA class II) surgical myectomy performed at comprehensive HCM centers (Table 3, Table 4) may be reasonable in the presence of additional clinical factors, including : a. Severe and progressive pulmonary hypertension thought to be attributable to LVOTO or associated MR; b. Left atrial enlargement with ≥1 episodes of symptomatic AF; c. Poor functional capacity attributable to LVOTO as documented on treadmill exercise testing ; d. Children and young adults with very high resting LVOT gradients (>100 mm Hg ). 2b C-LD 5. For symptomatic patients with obstructive HCM, SRT in eligible patients,* performed at experienced HCM centers † (Table 3, Table 4), may be considered as an alternative to escalation of medical therapy after shared decision-making including risks and benefits of all treatment options. 3: Harm C-LD 6. For patients with HCM who are asymptomatic and have normal exercise capacity, SRT is not recommended. 3: Harm B-NR 7. For symptomatic patients with obstructive HCM in whom SRT is an option, mitral valve replacement should not be performed for the sole purpose of relief of LVOTO. * General eligibility criteria for septal reduction therapy: (a) Clinical: Severe dyspnea or chest pain (usually NYHA functional class III or class IV), or occasionally other exertional symptoms (eg, syncope, near syncope), when attributable to LVOTO, that interferes with everyday activity or quality of life despite optimal medical therapy; (b) Hemodynamic: Dynamic LVOT gradient at rest or with physiologic provocation with approximate peak gradient of ≥50 mm Hg, associated with septal hypertrophy and SAM of mitral valve; and (c) Anatomic: Targeted anterior septal thickness sufficient to perform the procedure safely and effectively in the judgment of the individual operator. † Comprehensive or primary HCM centers with demonstrated excellence in clinical outcomes for these procedures (Table 3, Table 4).

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