ABC | Volume 112, Nº4, April 2019

Short Editorial Almeida Septal Ablation in oHCM Arq Bras Cardiol. 2019; 112(4):439-440 1. MaronBJ.Clinicalcourseandmanagementofhypertrophiccardiomyopathy. N Engl J Med. 2018;379(20):655-68. 2. Marian AJ, Braunwal E. Hypertrophic cardiomyopathy genetics, pathogenesis, clinical manifestations, diagnosis, and therapy. Circ Res. 2017;121(7):749-70. 3. Maron BJ, Ommem SR, Sensarian C. Spirito P, Maron S. Hypertrophic cardiomyopathy present and future, with translation into contemporary cardiovascular medicine. J Am Coll Cardiol. 2014;64(1):83-99. 4. Nishimura RA, Seggewiss H, Schaff HV. Hypertrophic obstructive cardiomyopathy: surgical myectomy and septal ablation. Circ Res. 2017;121(7):771-83. 5. Sigwart U. Non-surgical myocardial reduction for hypertrophic obstructive cardiomyopath. Lancet. 1995;346(8969):211-4. 6. Veselka J, Faber L, Liebregts M, Cooper R, Januska J, Krejci J, et al. Outcome of alcohol septal ablation inmildly symptomatic patients with hypertrophic obstructive cardiomyopathy: a long-term follow-Up study based on the Euro-Alcohol Septal Ablation Registry. J AmHeart Assoc. 2017;6(5):1-6. 7. Osman M, Kheiri B, Osman K, Barbarawi M, Alhamoud H, Alqahtani F, et al. Alcohol septal ablation vs myectomy for symptomatic hypertrophic obstructive cardiomyopathy: Systematic review and meta-analysis. Clin Cardiol. 2019; 42(1):190-7. 8. Vriesendorp PA, Liebregts M, Steggerda RC, Schinkel AFL. Long-Term outcomes aftermedical and Invasive Treatment in patients with hypertrophic cardiomyopathy. J Am Coll Cardiol Heart Fail. 2014;2(6)630-6. 9. Elliott PM, Anastasakis A, Borger MA. Guidelines on diagnosis and management of hipertrophic cardiomyopathy. Eur Heart J. 2014;35(39):2733-79. 10. Liebregts M, Faber L, Jansen MK, Vrisendorp A, Jamuska J, Krejeci J, et al. Outcomes of alcohol septal ablation in younger patients with obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol. 2017;10(11):1134-43. 11. Spirito P, Rossi J, Maron BJ. Alcohol septal ablation: in which patients and why? Ann Cardiothorac Surg. 2017;6(4):369-75. 12. Li CY, Shi YQ. Análise retrospectiva de fatores de risco para complicações relacionadas com ablação química na cardiomiopatia hipertrófica obstrutiva. Arq Bras Cardiol. 2019; 112(4):432-438. 13. Rigopoulos AG, Seggewiss H. Twenty years of alcohol septal ablation in hypertrophic obstructive cardiomyopathy. Curr Cardiol Rev. 2016;12(4):285-96. References This is an open-access article distributed under the terms of the Creative Commons Attribution License of low rates of complications, especially age, comorbidities, preexisting bundle branch blocks, as well as anatomical and functional factors as determinants of complications and also of the success rate of the procedure. 13 When selecting the patients for invasive treatment, one must ascertain the actual refractoriness of the clinical treatment (present in 5% of the patients in our center), evaluate the presence and impact of comorbidities, perform a careful assessment of the gradient, especially the resting gradient, since we do not know the actual influence of the inotropic stimulus on the genesis of the symptoms and the risk of death. The resting gradient should be >30 mmHg or ideally >50 mmHg; the basal septum thickness >15 mm or ideally >18 mm; one should determine that the gradient is in the outflow tract and not themid-ventricular portion (10-15%of cases), the presence of the anterior systolicmovement of themitral leaflet, degree andmechanismof mitral regurgitation, anatomy of the papillary muscle and, mainly, the anatomy of the dominant septal artery, collateral dependence, source of collateral, risk of remote infarction, and, finally, technical factors with appropriate material, balloon test to verify whether there is a gradient reduction, amount of alcohol to be injected and procedure monitoring with contrast echocardiogram to prevent large infarctions. 1,3,4,13 When choosing the type of invasive procedure, SM or SA, in addition to careful patient selection, one has to consider very thoroughly the fact that even symptomatic patients have an annual risk of death <3%. Thus, the availability of specialized centers and operators with experience in both procedures is mandatory, as both invasive procedures have only been shown to date to have an impact and reduce symptoms and improve quality of life, and none has shown to be capable of reducing the risk of sudden death, which is a major concern, especially in younger patients. 8,13 “We must always remember that the most important thing is to “treat the patient, not just the gradient.” 440