Percutaneous Intramyocardial Septal Radiofrequency Ablation (Liwen Procedure) for Hypertrophic Cardiomyopathy: A Decade of Evolution, Clinical Experience and Future Perspectives

doi:10.26599/AUDT.2026.260038

Abstract

Abstract:

Hypertrophic cardiomyopathy (HCM) is an inherited cardiomyopathy. For patients with obstructive hypertrophic cardiomyopathy (oHCM) who remain symptomatic despite medical therapy, septal reduction therapy can be performed. Surgical septal myectomy and alcohol septal ablation are the treatments for relieving left ventricular outflow tract obstruction and can effectively improve patients’ quality of life. In recent years, percutaneous intramyocardial septal radiofrequency ablation (PIMSRA/Liwen procedure) has emerged as a novel treatment for oHCM. This review traces its ten-year development from animal experiments to clinical application, covering technical principles, safety, and efficacy. Additional potentially extended applications are being explored, including non-obstructive HCM and other coexisting cardiac conditions. Future directions include longer-term follow-up, and multicenter collaboration to validate efficacy and safety in HCM patients. This review summarizes the current knowledge on PIMSRA/Liwen procedure and raises several issues that deserve further investigation.

Key words: Hypertrophic obstructive cardiomyopathy; Ventricular Septum; Radiofrequency ablation; Septal reduction therapy

Liu Liwen, Li Jing, Dang Shaonan, Hsi David H., Ta Shengjun. Percutaneous Intramyocardial Septal Radiofrequency Ablation (Liwen Procedure) for Hypertrophic Cardiomyopathy: A Decade of Evolution, Clinical Experience and Future Perspectives. Advanced Ultrasound in Diagnosis and Therapy, 2026, 10(4): 385-393.

/ Recommend

Figures/Tables 3

Figure 1

Table 1

Table 2

Efficacy of PIMSRA in patients with oHCM"

First Author, Year	Period	N	Age, year	Follow-up, months	Max IVS Thickness, mm	Peak LVOTPG, mmHg		NYHA Ⅲ-Ⅳ, %	MR		SAM grade 3, n (%)	LAVI, mL/m²	LVEF, %
First Author, Year	Period	N	Age, year	Follow-up, months	Max IVS Thickness, mm	resting	provoked	NYHA Ⅲ-Ⅳ, %	Moderate -Severe, %	mL	SAM grade 3, n (%)	LAVI, mL/m²	LVEF, %
Data are presented as mean, mean(SD), median, median(IQR) or %. ^a Data are presented as mean. ^b Data are presented as median. ^*P<0.05. PIMSRA, Percutaneous intramyocardial septal radiofrequency ablation; IVS, interventricular spetum; LVOTPG, left ventricular outflow tract-peak gradient; LVOT, left ventricular outflow tract; NYHA, New York Heart Association; MR, Mitral Regurgitation; SAM, Systolic Anterior Motion(of mitral valve); LAVI, Left Atrial Volume Index; LVEF, Left ventricular Ejection Fraction; SD, standard deviation; IQR, interquartile range.
Xijing HCM center
Zuo L, 2018[22]	2016-2017	1	70	6	28/18	153/44	-	-	-	7/3	-	65.7/47.9	65/-
Liu L, 2018[23]	-	1	26	6	-	88/10	-	-	-	-	-	-	-
Liu L, 2019[24]	2016-2017	9	46.1 ^a	6	21.5/12.9 ^a*	83.3/11.8 ^a*	147.8/25.5 ^a*	77.8/0^*	-	3.2/0.7^a*	-	-	-
Liu L, 2018[13]	-	15	40.7 ^a	6	25.0/14.0 ^b*	88.0/11.0 ^b*	117.0/25.0 ^b*	60/-	-	4.3/0.5^b*	-	41.9/29.6 ^b*	-
Zhou M, 2022[14]	2016-2020	200	46.9 ^a	19 (44) ^b	24.0/17.3 ^a*	79.0/14.0 ^b*	127.0/47.0 ^b*	71.0/4.0^*	-	-	53.0/3.0^*	49.5/35.9 ^a*	60.2/59.2 ^a*
Ta S, 2024[16]	2016-2017	27	44.3 ^a	60 (6.0) ^b	22.0/11.5 ^a*	95.0/9.0 ^b*	130.5/21.0 ^b*	63.0/0^*	44.7/11.5^*	-	40.7/0^*	60.8/51.3 ^a*	61.5/59.7 ^a
Zhang J, 2025[26]	2017-2023	12	48.7 ^a	12 (12) ^b	22.0/15.5 ^b*	82.5/15.5 ^b*	110.0/19.0 ^b*	66.7/8.3^*	-	-	-	48.2/40.8 ^b*	56.9/62.2 ^b*
Yao L, 2021[41]	2019-2020	45	46.8 ^a	6	24.0/17.0 ^b*	65.0/14.0 ^b*	-	26.7/0^*	-	-	-	-	59.3/58.8 ^a
Li J, 2022[45]	2016-2019	70	46.6 ^a	12	21.6/15.6 ^a*	83.5/13.5 ^b*	118.3/47.0 ^b*	62.9/-	-	-	-	52.0/37.8 ^a*	60.0/62.0 ^a
Zuo L, 2020[42]	2016-2018	30	45.0 ^b	12	23.3/14.4 ^a*	95.0/12.5 ^b*	-	43.3/-	-	5.8/2.0^b*		47.6/35.0 ^a*	62.6/59.3 ^a
Other center
Xie X, 2024[27]	2020-2023	76	55.7 ^a	14(11.5) ^b	23.6/19.1 ^b*	70.0/20.0 ^b*	104.3/41.4 ^b*	51.0/0^*	-	-	-	42.1/40.3 ^b*	71.2/69.1 ^a*
Wang C, 2024[28]	-	31	53 ^a	6	22.9/17.5 ^a*	83.2/23.4 ^a*	109.7/33.4 ^a*	71.0/3.2 ^*	41.9/6.5 ^*	-	-	32.3/23.9 ^a*	64.7/64.5 ^a
Wang S, 2025[29]	2019-2023	42	44.8 ^a	15(7.0) ^a	22.5/17.0 ^b*	58.5/11.5 ^b*	-	-	-	-	-	-	60.0/63.0 ^b*
Dai S, 2023[46]	2021	13	51.5 ^a	6	23.2/16.8 ^a*	64.9/14.3 ^a*	-	30.8/-	-	-	-	-	64.6/62.7 ^a

Table 2

References 58

[1]	Semsarian C, Ingles J, Maron MS, Maron BJ. New perspectives on the prevalence of hypertrophic cardiomyopathy. J Am Coll Cardiol 2015; 65: 1249-1254. doi: 10.1016/j.jacc.2015.01.019
[2]	Maron BJ, Gardin JM, Flack JM, Gidding SS, Kurosaki TT, Bild DE. Prevalence of hypertrophic cardiomyopathy in a general population of young adults. Echocardiographic analysis of 4111 subjects in the CARDIA Study. Coronary Artery Risk Development in (Young) Adults. Circulation 1995; 92: 785-789.
[3]	Ommen SR, Ho CY, Asif IM, Balaji S, Burke MA, Day SM, et al. 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the management of hypertrophic cardiomyopathy: a report of the american heart association/american college of cardiology joint committee on clinical practice guidelines. Circulation 2024; 149: e1239-1311. doi: 10.1161/cir.0000000000001277
[4]	Maron MS, Olivotto I, Zenovich AG, Link MS, Pandian NG, Kuvin JT, et al. Hypertrophic cardiomyopathy is predominantly a disease of left ventricular outflow tract obstruction. Circulation 2006; 114: 2232-2239. doi: 10.1161/CIRCULATIONAHA.106.644682
[5]	Maron MS, Olivotto I, Betocchi S, Casey SA, Lesser JR, Losi MA, et al. Effect of left ventricular outflow tract obstruction on clinical outcome in hypertrophic cardiomyopathy. N Engl J Med 2003; 348: 295-303. doi: 10.1056/NEJMoa021332
[6]	Nishimura RA, Seggewiss H, Schaff HV. Hypertrophic obstructive cardiomyopathy: surgical myectomy and septal ablation. Circ Res 2017; 121: 771-783. doi: 10.1161/CIRCRESAHA.116.309348
[7]	Maurizi N, Antiochos P, Owens A, Lakdawala N, Saberi S, Russell MW, et al. Long-Term outcomes after septal reduction therapies in obstructive hypertrophic cardiomyopathy: Insights From the SHARE Registry. Circulation 2024; 150: 1377-1390. doi: 10.1161/CIRCULATIONAHA.124.069378
[8]	Pavo N, Hengstenberg C. Management von kardiomyopathien. Herz 2024; 49: 22-32. doi: 10.1007/s00059-023-05224-z
[9]	Ommen SR, Mital S, Burke MA, Day SM, Deswal A, Elliott P, et al. 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2020; 142: e533-557. doi: 10.1161/cir.0000000000000945
[10]	Olivotto I, Ommen SR, Maron MS, Cecchi F, Maron BJ. Surgical myectomy versus alcohol septal ablation for obstructive hypertrophic cardiomyopathy. Will there ever be a randomized trial? J Am Coll Cardiol 2007; 50: 831-834.
[11]	Spirito P, Rossi J, Maron BJ. Alcohol septal ablation: in which patients and why?. Ann Cardiothorac Surg 2017; 6: 369-375.
[12]	Nagueh SF, Groves BM, Schwartz L, Smith KM, Wang A, Bach RG, et al. Alcohol septal ablation for the treatment of hypertrophic obstructive cardiomyopathy. A multicenter North American registry. J Am Coll Cardiol 2011; 58: 2322-2328.
[13]	Liu L, Li J, Zuo L, Zhang J, Zhou M, Xu B, et al. Percutaneous intramyocardial septal radiofrequency ablation for hypertrophic obstructive cardiomyopathy. J Am Coll Cardiol 2018; 72: 1898-1909. doi: 10.1016/j.jacc.2018.07.080
[14]	Zhou M, Ta S, Hahn RT, Hsi DH, Leon MB, Hu R, et al. Percutaneous intramyocardial septal radiofrequency ablation in patients with drug-refractory hypertrophic obstructive cardiomyopathy. JAMA Cardiol 2022; 7: 529-538. doi: 10.1001/jamacardio.2022.0259
[15]	Liu F, Fu J, Hsi D, Sun C, He G, Hu R, et al. Percutaneous intramyocardial septal radiofrequency ablation for interventricular septal reduction: an ovine model with 1-year outcomes. Cardiology 2020; 145: 53-62. doi: 10.1159/000502973
[16]	Ta S, Li J, Hsi DH, Hu R, Lei C, Shan B, et al. Percutaneous intramyocardial septal radiofrequency ablation after 5-year follow-up. Heart 2024; 110: 792-799. doi: 10.1136/heartjnl-2023-323606
[17]	Shah DR, Green S, Elliot A, McGahan JP, Khatri VP. Current oncologic applications of radiofrequency ablation therapies. World J Gastrointest Oncol 2013; 5: 71-80.
[18]	Fu J, Sun C, Liu F, Hu R, Hsi DH, Tuo S, et al. Transthoracic echocardiography guided percutaneous laser ablation of the interventricular septum: A successful sheep model for septal thickness reduction and one year follow-up. Int J Cardiol 2019; 280: 135-141. doi: 10.1016/j.ijcard.2019.01.007
[19]	Zhang X, Liu L, Sun C, He G, Zuo L, Zheng M, et al. Study of ultrasound-guided percutaneous laser ablation for canine ventricular septum. Chin J Ultrasonogr 2015; 24: 996-999.
[20]	Duan S, Wu Y, Wang S, Chang Z, Zhang Y, Liu Z, et al. A comparative experimental study of ultrasound-guided percutaneous interventricular septal myocardial ablation in dogs using laser and radiofrequency. Chin J Ultrasonogr 2020; 29: 717-721.
[21]	Li W, Liu J, Huang T, Zhong X, Yang D, Xie X, et al. Lesion outline and thermal field distribution of ablative in vitro experiments in myocardia: comparison of radiofrequency and laser ablation. BMC Cardiovasc Disord 2020; 20: 454. doi: 10.1186/s12872-020-01735-3
[22]	Zuo L, Sun C, Yang J, Liu B, Zhou M, Guo R, et al. Percutaneous trans-apex intra-septal radiofrequency ablation of hypertrophic cardiomyopathy. Minim Invasive Ther Allied Technol 2018; 27: 97-100. doi: 10.1080/13645706.2017.1378235
[23]	Liu L, Liu B, Li J, Zhang Y. Percutaneous intramyocardial septal radiofrequency ablation of hypertrophic obstructive cardiomyopathy: a novel minimally invasive treatment for reduction of outflow tract obstruction. EuroIntervention 2018; 13: e2112-2113. doi: 10.4244/EIJ-D-17-00657
[24]	Liu L, Zuo L, Zhou M, Li J, Zhou X, He G, et al. Efficacy and safety of transthoracic echocardiography-guided percutaneous intramyocardial septal radiofrequency ablation for the treatment of patients with obstructive hypertrophic cardiomyopathy. Chin J Cardiol 2019; 47: 1-8.
[25]	Yin J, Ta S, Wang J, Hsi DH, Shan B, Li J, et al. Predictive value of existing prediction models for short-term outcomes after percutaneous intramyocardial septal radiofrequency ablation. Cardiology 2026; 1: 1-11. doi: 10.1159/000551275
[26]	Zhang J, Hsi DH, Ta S, Wang J, Wang B, Ma H, et al. Percutaneous intramyocardial septal radiofrequency ablation for hypertrophic cardiomyopathy with residual obstruction after alcohol septal ablation. Can J Cardiol 2025; 41: 2397-2406.
[27]	Xie X, Chen S, Cui Y, Zhou Z, Lu J, Du Z, et al. Midterm outcomes of percutaneous intramyocardial septal radiofrequency ablation for hypertrophic cardiomyopathy: a single‐center, observational study. J Am Heart Assoc 2024; 13: e034080. doi: 10.1161/JAHA.123.034080
[28]	Wang C, Guo W, Duan H, Qin J, Wang F, He T, et al. Follow‐Up study of percutaneous intramyocardial septal radiofrequency ablation in the treatment of hypertrophic obstructive cardiomyopathy with HFpEF. Echocardiography 2024; 41: e15930. doi: 10.1111/echo.15930
[29]	Wang S, Tan J, Xiao H, Tao L. Clinical efficacy of Liwen procedure for obstructive hypertrophic cardiomyopathy: A retrospective study in a single center. Chin J Thorac Cardiovasc Surg 2025; 32: 819-823.
[30]	Liebregts M, Vriesendorp PA, Mahmoodi BK, Schinkel AFL, Michels M, Ten Berg JM. A systematic review and meta-analysis of Long-Term outcomes after septal reduction therapy in patients with hypertrophic cardiomyopathy. JACC Heart Fail 2015; 3: 896-905. doi: 10.1016/j.jchf.2015.06.011
[31]	Osman M, Kheiri B, Osman K, Barbarawi M, Alhamoud H, Alqahtani F, et al. Alcohol septal ablation vs myectomy for symptomatic hypertrophic obstructive cardiomyopathy: Systematic review and meta‐analysis. Clin Cardiol 2018; 42: 190-197.
[32]	Maron BJ, Maron MS. Hypertrophic cardiomyopathy. Lancet 2013; 381: 242-255. doi: 10.1016/S0140-6736(12)60397-3
[33]	Fujita Y, Kagiyama N, Sakuta Y, Tsuge M. Sudden hypoxemia after uneventful laparoscopic cholecystectomy: another form of SAM presentation. BMC Anesthesiol 2015; 15: 51. doi: 10.1186/s12871-015-0031-y
[34]	Makhija N, Magoon R, Balakrishnan I, Das S, Malik V, Gharde P. Left ventricular outflow tract obstruction following aortic valve replacement: A review of risk factors, mechanism, and management. Ann Card Anaesth 2019; 22: 1-5. doi: 10.4103/aca.aca_226_17
[35]	Shan B, Li J, Shi Z, Han C, Zhang J, Zhao J, et al. Predictive value of estimated plasma volume for postoperative hypotension in percutaneous intramyocardial septal radiofrequency ablation treating for hypertrophic obstructive cardiomyopathy. BMC Cardiovasc Disord 2024; 24: 177. doi: 10.1186/s12872-024-03844-9
[36]	Ibrahim M, Rao C, Ashrafian H, Chaudhry U, Darzi A, Athanasiou T. Modern management of systolic anterior motion of the mitral valve. Eur J Cardiothorac Surg 2012; 41: 1260-1270. doi: 10.1093/ejcts/ezr232
[37]	Lasala JD, Tsai J, Rodriguez-Restrepo A, Atay SM, Sepesi B. Systolic anterior motion of the mitral valve-the mechanism of postural hypotension following left intrapericardial pneumonectomy. J Thorac Dis 2017; 9: E354-357. doi: 10.21037/jtd.2017.03.117
[38]	Monaco F, D’Amico F, Barucco G, Licheri M, Novellis P, Ciriaco P, et al. Mitral valve systolic anterior motion in robotic thoracic surgery as the cause of unexplained hemodynamic shock: from a case report to recommendations. J Clin Med 2022; 11: 6044. doi: 10.3390/jcm11206044
[39]	Wu B, Zhou Y, Lu J, Cui Y, Zhou Z, Lin W, et al. Interventricular septal hematoma caused by percutaneous intramyocardial septal radiofrequency ablation successfully treated with coil embolization. JACC Cardiovasc Interv 2023; 16: 722-724.
[40]	Jiang S, Li H, Zhang L, Mu W, Zhang Y, Chen T, et al. Generic diagramming platform (GDP): a comprehensive database of high-quality biomedical graphics. Nucleic Acids Res 2024; 53: D1670-1676.
[41]	Yao L, Zuo L, Wang J, Lu X, Zhao J, He J, et al. Evaluation of myocardial microcirculation perfusion in patients with hypertrophic obstructive cardiomyopathy after Liwen procedure by myocardial contrast echocardiography. Chin J Ultrasonogr 2021; 30: 927-931.
[42]	Zuo L, Hsi DH, Zhang L, Zhang Q, Shao H, Liu B, et al. Electrocardiographic QRS voltage amplitude improvement by intramyocardial radiofrequency ablation in patients with hypertrophic obstructive cardiomyopathy and one year follow up. J Electrocardiol 2020; 61: 164-169. doi: 10.1016/j.jelectrocard.2020.06.013
[43]	Saito M, Okayama H, Yoshii T, Higashi H, Morioka H, Hiasa G, et al. Clinical significance of global two-dimensional strain as a surrogate parameter of myocardial fibrosis and cardiac events in patients with hypertrophic cardiomyopathy. Eur Heart J Cardiovasc Imaging 2012; 13: 617-623. doi: 10.1093/ejechocard/jer318
[44]	Maron MS, Wells S. Myocardial strain in hypertrophic cardiomyopathy: A force worth pursuing?. JACC Cardiovasc Imaging 2019; 12: 1943-1945.
[45]	Li J, Zhang J, Shi Y, Sievert H, Taub CC, Bertog S, et al. Myocardial mechanics of percutaneous intramyocardial septal radiofrequency ablation. Heart 2023; 109: 289-296. doi: 10.1136/heartjnl-2022-321597
[46]	Dai S, Wu L, Duan H, Wang H, Song X, Guo W, et al. Analysis of left atrial function after percutaneous intramyocardial septal radiofrequency ablation in hypertrophic cardiomyopathy. Cardiology 2023; 148: 38-47. doi: 10.1159/000528030
[47]	National Heart Failure Committee, Chinese Heart Failure Association of Chinese Medical Doctor Association, Heart Failure Group of Chinese Society of Cardiology of Chinese Medical Association, Editorial Board of Chinese Journal of Heart Failure. 2022 Chinese guideline for hypertrophic cardiomyopathy. Chin J Heart Fail Cardiomyopathy 2022; 6: 80-105.
[48]	The Joint Committee of Cardiomyopathy Specialty Alliance, National Center for Cardiovascular Diseases/Cardiovascular Precision Medicine Branch of China International Exchange, Promotive Association for Medical, Health Care. 2023 Guideline for Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy. Chin Circ J 2023; 38: 1-33.
[49]	The Cardiomyopathy Specialty Alliance of National Center for Cardiovascular Diseases, Cardiovascular Precision Medicine Branch of China International Exchange, Promotive Association for Medical, Health Care. 2025 Chinese guideline for the management of cardiomyopathies. Mol Cardiol China 2025; 25: 6793-6837.
[50]	Olivotto I, Cecchi F, Poggesi C, Yacoub MH. Patterns of disease progression in hypertrophic cardiomyopathy: an individualized approach to clinical staging. Circ Heart Fail 2012; 5: 535-546. doi: 10.1161/CIRCHEARTFAILURE.112.967026
[51]	Rowin EJ, Maron BJ, Kiernan MS, Casey SA, Feldman DS, Hryniewicz KM, et al. Advanced heart failure with preserved systolic function in nonobstructive hypertrophic cardiomyopathy: under-recognized subset of candidates for heart transplant. Circ Heart Fail 2014; 7: 967-975. doi: 10.1161/CIRCHEARTFAILURE.114.001435
[52]	Wang H, Li J, Hsi DH, Li W, Ta S, Jiao Y, et al. Percutaneous intramyocardial septal radiofrequency ablation: a novel treatment for drug-refractory non-obstructive hypertrophic cardiomyopathy with severe septal hypertrophy. Heart 2025; 111: e325334
[53]	Xu Y, Yu T, Pu Z. Percutaneous Intramyocardial Septal Radiofrequency Ablation Relieving Residual Left Ventricular Outflow Tract Obstruction Following Alcohol Septal Ablation. CASE 2022; 6: 340-343. doi: 10.1016/j.case.2022.06.003
[54]	Li X, Xie S, Yu Z. Concomitant Liwen procedure and minimally invasive direct coronary artery bypass via a single access: a first-in-human case report. Eur Heart J Case Rep 2026; 10: ytag312. doi: 10.1093/ehjcr/ytag312
[55]	Zhang R, Zhao F, Wang J, Qin Y, Wang T, Chu A-A. Case Report: Integrated echocardiographic assessment guided Liwen procedure for treating obstructive hypertrophic cardiomyopathy with ventricular aneurysm. Front Cardiovasc Med 2023; 10: 1278457. doi: 10.3389/fcvm.2023.1278457
[56]	Yin J, Yang S, Yang F, Li J, Zhao Y. Percutaneous intramyocardial septal radiofrequency ablation for a Fabry disease patient. Eur Heart J Cardiovasc Imaging 2025; 26: 1081
[57]	Shi X, Yang F, Wang J, Han C, Liu L. Echocardiography-guided percutaneous intramyocardial septal radiofrequency ablation procedure for the treatment of Fabry disease: a case report. Eur Heart J Case Rep 2025; 9: ytae660
[58]	Huang J, Lei C, Hsi DH, Zheng M, Ma H, Ta S, et al. Echocardiography-guided radiofrequency ablation for cardiac tumors. JACC CardioOncol 2024; 6: 560-571. doi: 10.1016/j.jaccao.2024.03.008

Items	PIMSRA/Liwen procedure	SM	ASA
PIMSRA, percutaneous intramyocardial septal radiofrequency ablation; SM. surgical myectomy; ASA, alcohol septal ablation; TTE, transthoracic echocardiography; TEE, transesophageal echocardiography; MCE, myocardial contrast echocardiography.
Approach	Percutaneous intramyocardial	Open-chest approach via median sternotomy	Percutaneous catheter‑based
Mechanism	Radiofrequency ablation	Resection	Chemical ablation
Scarring	YES, homogeneous	NO	YES, heterogeneous
Intraoperative imaging	TTE	TEE	Fluoroscopy+MCE
Fluoroscopy	None, Echo-only	Not typically required	Required (fluoroscopy for coronary angiography)
Cardiopulmonary bypass	NO	YES	NO
Constrained by coronary anatomy	NO	NO	YES