Rational Choice of Medical and/or Surgical Therapy in Hypertrophic Cardiomyopathy

  • E. D. Wigle
  • W. G. Williams
  • B. Kimball
  • Z. Sasson
  • H. Rakowski


A rational choice between medical and surgical therapy in any disease entity can only exist when both forms of therapy are possible. In hypertrophic cardiomyopathy (HCM), there is a choice between medical and surgical therapy in the clinical syndromes listed in Table 1. In this review, we will discuss the various forms of medical and surgical therapy that are available to patients with HCM, but will focus on the Toronto experience, which is based on the hemodynamic classification of this disease [1–6]. We will not discuss those forms of HCM that are only amenable to medical therapy, because in those there is no rational choice between medical and surgical therapy.


Mitral Regurgitation Hypertrophic Cardiomyopathy Mitral Leaflet Systolic Anterior Motion Left Ventricular Stroke Volume 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Wigle ED, Heimbecker RO, Gunton RW (1962) Idiopathic ventricular septal hypertrophy causing muscular subaortic stenosis. Circulation 26: 325–340PubMedGoogle Scholar
  2. 2.
    Wigle ED, Adelman MD, Felderhof CH (1974) Medical and surgical treatment of the cardiomyopathies. Circ Res 34, 35 II-196–207Google Scholar
  3. 3.
    Wigle ED, Sasson Z, Henderson MA, Ruddy TD, Fulop J, Rakowski H, Williams WG (1985) Hypertrophic cardiomyopathy. The importance of the site and the extent of hypertrophy. A review. Prog Cardiovasc Dis 28: 1–83PubMedCrossRefGoogle Scholar
  4. 4.
    Wigle ED (1987) Hypertrophic cardiomyopathy. A 1987 viewpoint. (Editorial) Circulation 75: 311–322CrossRefGoogle Scholar
  5. 5.
    Wigle ED, Rakowski H (1987) Evidence for true obstruction to left ventricular outflow in obstructive hypertrophic cardiomyopathy (muscular of hypertrophic subaortic stenosis). Z Kardiol 76: 61–68PubMedGoogle Scholar
  6. 6.
    Wigle ED (1988) Hypertrophic cardiomyopathy 1988. Mod Concepts Cardiovasc Dis 57: 1–6Google Scholar
  7. 7.
    Murgo JP, Alter BR, Dorethy JF, Altobelli SA, McGranahan GM Jr (1980) Dynamics of left ventricular ejection in obstructive and nonobstructive hypertrophic cardiomyopathy. J Clin Invest 66: 1369–1382PubMedCrossRefGoogle Scholar
  8. 8.
    Falicov RE,Resnekov L, Bharati S et al (1976) Midventricular obstruction: a variant of obstructive cardiomyopathy. Am J Cardiol 37: 432–437PubMedCrossRefGoogle Scholar
  9. 9.
    Criley MJ, Lewis KB, White RI, Ross RS (1965) Pressure gradients without obstruction: a new concept of “hypertrophic subaortic stenosis”. Circulation 22: 881–887Google Scholar
  10. 10.
    Grose RM, Strain JE, Spindola-Franco H (1986) Angiographic and hemodynamic correlations in hypertrophic cardiomyopathy. Am J Cardiol 58: 1085–1092PubMedCrossRefGoogle Scholar
  11. 11.
    Wigle ED, Auger P, Marquis Y (1966) Muscular subaortic stenosis: the initial left ventricular inflow tract pressure as evidence of outflow tract obstruction. Can Med Assoc J 95: 793–797PubMedGoogle Scholar
  12. 12.
    Wigle ED, Marquis Y, Auger P (1967) Muscular subaortic stenosis: Initial left ventricular inflow tract pressure in the assessment of intraventricular pressure differences in man. Circulation 35: 1100–1117PubMedGoogle Scholar
  13. 13.
    Criley MJ, Seigel RJ (1985) Has ‘obstruction’ hindered our understanding of hypertrophic cardiomyopathy? Circulation 72: 1148–1154PubMedCrossRefGoogle Scholar
  14. 14.
    Wigle ED, Adelman AG, Silver MD (1971) Pathophysiological considerations in muscular subaortic stenosis. In: Wolstenholme GEW, O’Connor M (eds) Hypertrophic obstructive cardiomyopathy. Ciba Foundation Study Group 47. Ciba Foundation, London, pp 63–76Google Scholar
  15. 15.
    Gilbert BW, Pollick C, Adelman AG, Wigle ED (1980) Hypertrophic cardiomyopathy: subclassification by M-mode echocardiography. Am J Cardiol 45: 861PubMedCrossRefGoogle Scholar
  16. 16.
    Pollick C, Gilbert BW, Rakowski H, Morgan CD, Wigle ED (1982) Muscular subaortic stenosis: the temporal relationship between systolic anterior motion of the anterior mitral leaflet and the pressure gradient. Circulation 66: 1087–1093PubMedCrossRefGoogle Scholar
  17. 17.
    Pollick C, Rakowski H, Wigle ED (1984) Muscular subaortic stenosis: the quantitative relationship between systolic anterior motion and the pressure gradient. Circulation 69-1: 43–49CrossRefGoogle Scholar
  18. 18.
    Glasgow GA, Gardin JM, Burns CS, Childs WJ, Henry WL (1980) Echocardiographic and Doppler flow observations in idiopathic hypertrophic subaortic stenosis (IHSS) Circulation 62:III-99 (abstr)Google Scholar
  19. 19.
    Bonow RO, Ostrow HG, Rosing DR, Cannon RO, Leon MB, Watson RM, Bacharach SL, Green MV, Epstein SE (1984) Dynamic pressure-volume alterations during left ventricular ejection in hypertrophic cardiomyopathy: evidence for true obstruction to left ventricular outflow. Circulation 70: 11–17 (abstr)Google Scholar
  20. 20.
    Hatle L, Angelsen B (1985) (eds) Doppler ultrasound in cardiology. Lea and Febiger, Philadelphia, pp 205–217Google Scholar
  21. 21.
    Bonow RO, Crawford-Green C, Betocci S, Rosing DR, Maron BJ (1985) Left ventricular ejection dynamics in hypertrophic cardiomyopathy: comparison with valvular aortic stenosis. J Am Coll Cardiol 5: 395 (abstr)Google Scholar
  22. 22.
    Pouleur H Van Eyll C, Gurne O, Hanet C, Rousseau MF (1985) Regional velocity of shortening in hypertrophic cardiomyopathy: evidence for true impedance to shortening in the presence of outflow gradients. Circulation 72: 111–448 (abstr)Google Scholar
  23. 23.
    Rakowski H, Sasson Z, Wigle ED (1988) Echocardiographic and Doppler assessment of hypertrophic cardiomyopathy. J Am Soc Echo 1: 31–47Google Scholar
  24. 24.
    Stewart WJ, Schiavone WA, Salcedo EE, Lever HM, Cosgrove DM, Grill CC (1985) Intraoperative Doppler velocity correlates with outflow gradient in HOCM pre- and postmyectomy. Circulation 72: 111–447 (abstr)Google Scholar
  25. 25.
    Holt B, Sahn DJ, Dalton N, Smith SC, Yun Y, Dittrich H (1985) Color Doppler flow mapping studies of jet formation in hypertrophic cardiomyopathy (HCM). Circulation 72: 111–447 (abstr)Google Scholar
  26. 26.
    Sasson Z, Yock PG, Hatle LK, Alderman EL, Popp R (1986) Noninvasive determination of the pressure gradient in hypertrophic cardiomyopathy. Circulation 74: 11–215 (abstr)Google Scholar
  27. 27.
    Wigle ED, Adelman AG, Auger P, Marquis Y (1969) Mitral regurgitation in muscular subaortic stenosis. Am J Cardiol 24: 698–706PubMedCrossRefGoogle Scholar
  28. 28.
    Adelman AG, McLoughlin MJ, Marquis Y, Auger P, Wigle ED (1969) Left ventricular cineangiographic observations in muscular subaortic stenosis. Am J Cardiol 24: 689–697PubMedCrossRefGoogle Scholar
  29. 29.
    Ross J Jr, Braunwald E, Gault JH, Mason DT, Morrow AG (1966) The mechanism of the intraventricular pressure gradient in idiopathic hypertrophic subaortic stenosis. Circulation 34: 558–578PubMedGoogle Scholar
  30. 30.
    Wigle ED, Auger P, Marquis Y (1967) Muscular subaortic stenosis: the direct relation between the intraventricular pressure gradient and left ventricular ejection time. Circulation 36: 36–44PubMedGoogle Scholar
  31. 31.
    Sasson Z, Henderson M, Wilansky S, Rakowski H, Wigle ED (1989) Causal relation between the pressure gradient and left ventricular ejection time in hypertrophic cardiomyopathy. J Am Coll Cardiol 13: 1275–1279PubMedCrossRefGoogle Scholar
  32. 32.
    Maron BJ, Gottdiener JS, Arce J, Rosing DR, Wesley YE, Epstein SE (1985) Dynamic subaortic obstruction in hypertrophic cardiomyopathy: analysis by pulsed Doppler echocardiography. J Am Coll Cardiol 6: 1–15PubMedCrossRefGoogle Scholar
  33. 33.
    Pierce GE, Morrow AG, Braunwad E (1964) Idiopathic hypertrophic subaortic stenosis III. Intraoperative studies of the mechanism of obstruction and its hemodynamic consequences. Circulation 30:IV, 152–207Google Scholar
  34. 34.
    Bircks W, Bostroem B, Gleichmann U, Kruezer H, Loogen F (1968) Electromagnetic flow measurement in the ascending aorta before and after repair of valvular and subvalvular lesions including IHSS. Proceedings of the Vth European Congress of Cardiology (Athens), pp 13–22Google Scholar
  35. 35.
    Jenni R, Ruffman K, Vieli A, Anlinker M, Krayenbuehl HP (1985) Dynamics of aortic flow in hypertrophic cardiomyopathy. Eur Heart J 6: 391–398PubMedGoogle Scholar
  36. 36.
    Hernandez RR, Greenfiled JC Jr, McCall BW (1964) Pressure-flow studies in hypertrophic subaortic stenosis. J Clin Invest 43: 401–107PubMedCrossRefGoogle Scholar
  37. 37.
    Cannon RO, Rosing DR, Mcintosh CL, Epstein SE (1985) Hypertrophic cardiomyopathy (HCM): improved hemodynamics, metabolism, and anginal threshold following surgical relief of obstruction. Circulation 72:III–447 (abstr)Google Scholar
  38. 38.
    Frank MJ, Abdulla AM, Watkins O, Prisant L, Stefadouros MA (1983) Long-term medical management of hypertrophic cardiomyopathy: usefulness of propranolol. Eur Heart J 4: 155–164PubMedGoogle Scholar
  39. 39.
    Kaltenbach M, Hopf R, Kober G, Bussman WD, Keller M, Petersen Y (1979) Treatment of hypertrophic obstructive cardiomyopathy with verapamil. Br Heart J 42: 35–42PubMedCrossRefGoogle Scholar
  40. 40.
    Kaltenbach M, Hopf R (1985) Treatment of hypertrophic cardiomyopathy: Relation to pathological mechanisms. J Mol Cell Cardiol 17: 59–68PubMedCrossRefGoogle Scholar
  41. 41.
    Rosing DR, Kent KM, Border JS, Seides SF, Maron BJ, Epstein SE (1979) Verapamil therapy: a new approach to the pharmacologic treatment of hypertrophic cardiomyopathy I. Hemodynamic effects. Circulation 60: 1201–1207PubMedGoogle Scholar
  42. 42.
    Rosing DR, Condit JR, Maron BJ, Kent KM, Leon MB, Bonow RO, Lipson LC, Epstein SE (1981) Verapamil therapy: A new approach to the pharmacologic treatment of hypertrophic cardiomyopathy: III. Effects of long-term administration. Am J Cardiol 48: 545–553PubMedCrossRefGoogle Scholar
  43. 43.
    Rosing DR, Idanpaan-Heikkila U, Maron BJ, Bonnow RO, Epstein SE (1985) Use of calcium-channel blocking drugs in hypertrophic cardiomyopathy. Am J Cardiol 55 (Suppl) 185B–195BPubMedCrossRefGoogle Scholar
  44. 44.
    Pollick C (1982) Muscular subaortic stenosis. Hemodynamic and clinical improvement after disopyramide. N Eng J Med 307: 997–999CrossRefGoogle Scholar
  45. 45.
    Pollick C, Kimball B, Henderson M, Wigle ED (1988) Disopyramide in hypertrophic cardiomyopathy I. Hemodynamic assessment after intravenous administration. Am J Cardiol 62: 1248–1251PubMedCrossRefGoogle Scholar
  46. 46.
    Wigle ED, Chrysohou A, Bigelow W (1963) Results of ventriculomyotomy in muscular subaortic stenosis. Am J Cardiol 11: 572–586PubMedCrossRefGoogle Scholar
  47. 47.
    Bigelow WG, Trimble AS, Wigle ED, Adelman AG, Felderhof C (1974) The treatment of muscular subaortic stenosis. Thorac Cardiovasc Surg 68: 384–392Google Scholar
  48. 48.
    Williams WG, Wigle ED, Rakowski H, Smallhorn J, Le Blanc J, Trusler GA (1987) Results of surgery for idiopathic hypertrophic obstructive cardiomyopathy (IHSS). Circulation 76-II: 104–108Google Scholar
  49. 49.
    McKenna WJ, England D, Doi YL, Deanfiled JE, Oakley C, Goodwin JF (1981) Arrhythmia in hypertrophic cardiomyopathy I. Influence on prognosis. Br Heart J 46: 168–172PubMedCrossRefGoogle Scholar
  50. 50.
    Shah PM, Adelman AG, Wigle ED et al (1975) The natural (and unnatural) history of hypertrophic obstructive cardiomyopathy. Circ Res 34, 35 (Suppl 2): 179–186Google Scholar
  51. 51.
    Maron BJ, Epstein SE, Morrow AG (1983) Symptomatic status and prognosis of patients after operation for hypertrophic obstructive cardiomyopathy and myectomy. Eur Heart J 4 (Suppl F): 175–185PubMedGoogle Scholar
  52. 52.
    Beahrs MM, Tajak AJ, Seward JB et al (1983) Hypertrophic obstructive cardiomyopathy: 10–21 year follow-up after partial septal myectomy. Am J Cardiol 51: 1160–1166PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 1990

Authors and Affiliations

  • E. D. Wigle
  • W. G. Williams
  • B. Kimball
  • Z. Sasson
  • H. Rakowski

There are no affiliations available

Personalised recommendations