The evolving clinical practice of septal reduction therapy in hypertrophic obstructive cardiomyopathy

Hypertrophic obstructive cardiomyopathy remains a formidable clinical challenge, and septal reduction therapy (SRT) continues to be the cornerstone for managing drug-refractory left ventricular outflow tract obstruction. Over the past decade, SRT has undergone remarkable refinement and diversification. Traditional strategies - surgical septal myectomy and alcohol septal ablation - have been continually optimized, demonstrating durable relief of left ventricular outflow tract obstruction and sustained symptomatic improvement. Emerging techniques, including percutaneous intramyocardial septal radiofrequency ablation, transapical beating-heart myectomy, transcoronary radiofrequency ablation, and endoluminal electrosurgical myotomy, offer promising, less-invasive alternatives that achieve hemodynamic outcomes comparable to surgery. Nevertheless, long-term data on these novel procedures are scarce, and evidence-based algorithms for matching individual patients to the optimal technique remain elusive. This review synthesizes 65 years of technical evolution in SRT and proposes an evidence-driven framework for individualized procedure selection that integrates anatomical complexity, patient-specific risk profiles, and institutional expertise, thereby advancing the field toward truly personalized and effective care.