Novel off-pump ventricular septal myectomy for obstructive hypertrophic cardiomyopathy: A paradigm shift in surgical management

Abstract

Obstructive hypertrophic cardiomyopathy (oHCM) presents a significant clinical challenge, with left ventricular outflow tract obstruction being a primary driver of symptoms and adverse outcomes. Surgical septal myectomy (SM) performed under cardiopulmonary bypass and cardioplegic arrest has stood as the gold standard therapy, offering durable and complete relief of obstruction. However, its widespread adoption has been severely hampered by the limited surgical field, lack of real-time intraoperative assessment, and steep learning curve. In an effort to streamline SM, we have developed an innovative transapical beating-heart SM (TA-BSM) procedure. In this article, we outline the design of the beating-heart myectomy device that enables off-pump, real-time assessment of resection via a small left thoracotomy. We synthesize the evidence from the initial feasibility study in swine, the first-in-human trial, and large-scale clinical applications, indicating its compelling safety and efficacy profile. Furthermore, we analyze the learning curve of the TA-BSM procedure and present a structured framework for training future surgeons. Finally, we discuss the profound implications of this technique for global dissemination of oHCM care, potentially making this life-changing surgery accessible to thousands of underserved patients worldwide. In summary, TA-BSM represents not merely an incremental improvement but a true paradigm shift, moving oHCM surgery from a static, blind procedure to a dynamic, precise intervention.