This brief review summarizes how patients are selected for myectomy or alcohol septal ablation and reviews results for both procedures. The most recent literature is reviewed for both septal myectomy and alcohol ablation. The mechanisms for obstruction and mitral regurgi- tation as well as the indications for both procedures are reviewed. Septal myectomy gives a more consistent relief of the gradient with very low morbidity and mortality. The mortality for alcohol septal ablation is higher than for surgery. In addition, the need for a permanent pa- cemaker is higher for patients undergoing septal ablation. There maybe an increased risk for ventricular arrhythmia post ablation. Septal myectomy is the gold standard for the invasive treatment of hypertrophic cardiomyopathy. Septal ablation should be considered for the elderly or patients with co-morbid conditions that would make surgery at increased risk.