Fifty years ago, the first modern reports of what we now recognise as HCM were authored by a surgeon, Sir Russell Brock, and a pathologist, Donald Teare. These classical papers stimulated an intense and sometimes controversial field of study, focussed in large part on the characterisation of left ventricular outflow tract obstruction. Detailed invasive haemodynamic investigations highlighted the extraordinary dynamic nature of this new form of outflow obstruction, and numerous surgical therapies were proposed and abandoned. The introduction of echocardiography allowed investigators to determine the mechanism for obstruction–an adverse interaction between a hypertrophied septum and abnormal movement of the mitral valve toward the septum–but also showed that obstruction was not a universal feature of the disease. The focus of this article is to review the historical controversies surrounding left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, and to discuss the modern approach to its assessment and treatment.
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