LV obstruction is a significant risk factor for sudden cardiac death and heart failure in HOCM pts. According to European guidelines, ICD implantation is based on HCM-SCD calculator that includes LV gradient as one of the risk factors. Should we first eliminate obstruction and re-evaluate the pt before possible ICD implantation?
I strongly believe, we should, because the risk profile after the reduction/elimination of LV obstruction is better than before. Thus, we should change guidelines in this point.
Since 2014 we have new evidence about a long-term safety, a durable effect, safety and efficacy in young and mildly symptomatic pts, safety and better long-term prognosis in pts with a thin septum, a necessity of reduction of gradient to less than 30 mmHg, safety and efficacy of redo procedures, a need of institutional/expert experience, improvement of SCD risk profile etc.
Thickness of septum and extent of LVOT gradient are important predictors of SCD in HCM. But there are other equally important variables which cannot be ignored while assessing the risk of SCD. Moreover, there is no linear relation between thickness of IVS and extent of LVOT gradient in several patients. Also, alcohol septal ablation and consequent scar are matters of concern especially in young patients. Risk stratification after eliminating or reducing the LVOT gradient has several limitations and may not be practical.
It would be interesting to know data confirming limited use of ASA in young pts. (Liebregts et al. Jacc Intv and Veselka et al. Can J Cardiol demonstrated safety and efficacy) or limited use of SCD HCM calculator after ASA (Liebregts et al, Europace demonstrated general limitations of the calculator, but possibility to use it after ASA).
No doubt, septum thickness and gradient have no linear relationship, since obstruction has several further important components.
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