The new life of myectomy in the era of myosin inhibitors

: The management of symptomatic obstructive hypertrophic cardiomyopathy remains a therapeutic clinical challenge. Surgical septal myectomy has long been established as the gold-standard intervention for patients with persistent symptoms despite optimal medical therapy, offering durable symptom relief with low perioperative risk in experienced centers. Recently, the introduction of cardiac myosin inhibitors, such as mavacamten and aficamten, has reshaped the treatment paradigm for obstructive hypertrophic cardiomyopathy. By selectively inhibiting cardiac myosin ATPase activity, these agents reduce hypercontractility and improve myocardial energetic efficiency. Randomized, placebo-controlled trials such as EXPLORER-HCM and SEQUOIA-HCM have demonstrated the efficacy of cardiac myosin inhibitors in reducing left ventricular outflow tract gradients, alleviating symptoms, and enhancing functional capacity in patients with obstructive hypertrophic cardiomyopathy. The growing clinical use of cardiac myosin inhibitors raises critical questions regarding their role relative to surgical intervention. While cardiac myosin inhibitors offer an effective and less invasive alternative for many patients, they do not fully replace surgical myectomy across all clinical settings. This review articles explores the evolving therapeutic landscape of obstructive hypertrophic cardiomyopathy, focusing on the comparative advantages and limitations of cardiac myosin inhibitors and surgical myectomy.