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Maron MS, Mahmod M, Abd Samat AH, Choudhury L, Massera D, Phelan DMJ, Cresci S, Martinez MW, Masri A, Abraham TP, Adler E, Wever-Pinzon O, Nagueh SF, Lewis GD, Chamberlin P, Patel J, Yavari A, Dehbi HM, Sarwar R, Raman B, Valkovič L, Neubauer S, Udelson JE, Watkins H. Safety and Efficacy of Metabolic Modulation With Ninerafaxstat in Patients With Nonobstructive Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2024; 83:2037-2048. [PMID: 38599256 DOI: 10.1016/j.jacc.2024.03.387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND In nonobstructive hypertrophic cardiomyopathy (nHCM), there are no approved medical therapies. Impaired myocardial energetics is a potential cause of symptoms and exercise limitation. Ninerafaxstat, a novel cardiac mitotrope, enhances cardiac energetics. OBJECTIVES This study sought to evaluate the safety and efficacy of ninerafaxstat in nHCM. METHODS Patients with hypertrophic cardiomyopathy and left ventricular outflow tract gradient <30 mm Hg, ejection fraction ≥50%, and peak oxygen consumption <80% predicted were randomized to ninerafaxstat 200 mg twice daily or placebo (1:1) for 12 weeks. The primary endpoint was safety and tolerability, with efficacy outcomes also assessed as secondary endpoints. RESULTS A total of 67 patients with nHCM were enrolled at 12 centers (57 ± 11.8 years of age; 55% women). Serious adverse events occurred in 11.8% (n = 4 of 34) in the ninerafaxstat group and 6.1% (n = 2 of 33) of patients in the placebo group. From baseline to 12 weeks, ninerafaxstat was associated with significantly better VE/Vco2 (ventilatory efficiency) slope compared with placebo with a least-squares (LS) mean difference between the groups of -2.1 (95% CI: -3.6 to -0.6; P = 0.006), with no significant difference in peak VO2 (P = 0.90). The Kansas City Cardiomyopathy Questionnaire Clinical Summary Score was directionally, though not significantly, improved with ninerafaxstat vs placebo (LS mean 3.2; 95% CI: -2.9 to 9.2; P = 0.30); however, it was statistically significant when analyzed post hoc in the 35 patients with baseline Kansas City Cardiomyopathy Questionnaire Clinical Summary Score ≤80 (LS mean 9.4; 95% CI: 0.3-18.5; P = 0.04). CONCLUSIONS In symptomatic nHCM, novel drug therapy targeting myocardial energetics was safe and well tolerated and associated with better exercise performance and health status among those most symptomatically limited. The findings support assessing ninerafaxstat in a phase 3 study.
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Affiliation(s)
- Martin S Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA.
| | - Masliza Mahmod
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Azlan Helmy Abd Samat
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Lubna Choudhury
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniele Massera
- Hypertrophic Cardiomyopathy Program, Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York, USA
| | - Dermot M J Phelan
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Sharon Cresci
- Center for Cardiovascular Research, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Matthew W Martinez
- Division of Cardiology, Atlantic Health System, Morristown, New Jersey, USA
| | - Ahmad Masri
- Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Theodore P Abraham
- Division of Cardiology, University of California-San Francisco, San Francisco, California, USA
| | - Eric Adler
- Division of Cardiovascular Medicine, Department of Medicine, University of California-San Diego, La Jolla, California, USA
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Sherif F Nagueh
- Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Gregory D Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Jai Patel
- Imbria Pharmaceuticals, Boston, Massachusetts, USA
| | - Arash Yavari
- Imbria Pharmaceuticals, Boston, Massachusetts, USA
| | | | | | - Betty Raman
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Ladislav Valkovič
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Stefan Neubauer
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - James E Udelson
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Hugh Watkins
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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Coats CJ, Maron MS, Abraham TP, Olivotto I, Lee MMY, Arad M, Cardim N, Ma CS, Choudhury L, Düngen HD, Garcia-Pavia P, Hagège AA, Lewis GD, Michels M, Oreziak A, Owens AT, Tfelt-Hansen J, Veselka J, Watkins HC, Heitner SB, Jacoby DL, Kupfer S, Malik FI, Meng L, Wohltman A, Masri A. Exercise Capacity in Patients With Obstructive Hypertrophic Cardiomyopathy: SEQUOIA-HCM Baseline Characteristics and Study Design. JACC. HEART FAILURE 2024; 12:199-215. [PMID: 38032573 DOI: 10.1016/j.jchf.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/03/2023] [Accepted: 10/11/2023] [Indexed: 12/01/2023]
Abstract
Patients with obstructive hypertrophic cardiomyopathy (oHCM) have increased risk of arrhythmia, stroke, heart failure, and sudden death. Contemporary management of oHCM has decreased annual hospitalization and mortality rates, yet patients have worsening health-related quality of life due to impaired exercise capacity and persistent residual symptoms. Here we consider the design of clinical trials evaluating potential oHCM therapies in the context of SEQUOIA-HCM (Safety, Efficacy, and Quantitative Understanding of Obstruction Impact of Aficamten in HCM). This large, phase 3 trial is now fully enrolled (N = 282). Baseline characteristics reflect an ethnically diverse population with characteristics typical of patients encountered clinically with substantial functional and symptom burden. The study will assess the effect of aficamten vs placebo, in addition to standard-of-care medications, on functional capacity and symptoms over 24 weeks. Future clinical trials could model the approach in SEQUOIA-HCM to evaluate the effect of potential therapies on the burden of oHCM. (Safety, Efficacy, and Quantitative Understanding of Obstruction Impact of Aficamten in HCM [SEQUOIA-HCM]; NCT05186818).
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Affiliation(s)
- Caroline J Coats
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom.
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center at Lahey Medical Center, Burlington, Massachusetts, USA
| | | | - Iacopo Olivotto
- Meyer Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Florence, Italy
| | - Matthew M Y Lee
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Michael Arad
- Leviev Heart Center, Sheba Medical Center, Israel; Tel Aviv University, Medical School, Israel
| | | | - Chang-Sheng Ma
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lubna Choudhury
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro de Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Albert A Hagège
- Département de Cardiologie, Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges-Pompidou, Paris, France
| | | | | | | | - Anjali T Owens
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jacob Tfelt-Hansen
- Section of Forensic Genetics, Department of Forensic Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Josef Veselka
- University Hospital Motol and 2nd Medical School, Charles University, Prague, Czech Republic
| | - Hugh C Watkins
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Daniel L Jacoby
- Cytokinetics Incorporated, South San Francisco, California, USA
| | - Stuart Kupfer
- Cytokinetics Incorporated, South San Francisco, California, USA
| | - Fady I Malik
- Cytokinetics Incorporated, South San Francisco, California, USA
| | - Lisa Meng
- Cytokinetics Incorporated, South San Francisco, California, USA
| | - Amy Wohltman
- Cytokinetics Incorporated, South San Francisco, California, USA
| | - Ahmad Masri
- Oregon Health and Science University, Portland, Oregon, USA
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3
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Tian Z, Li L, Li X, Wang J, Zhang Q, Li Z, Peng D, Yang P, Ma W, Wang F, Jin W, Cheng X, Sun J, Fu Y, Lyu C, Zhang S. Effect of Mavacamten on Chinese Patients With Symptomatic Obstructive Hypertrophic Cardiomyopathy: The EXPLORER-CN Randomized Clinical Trial. JAMA Cardiol 2023; 8:957-965. [PMID: 37639259 PMCID: PMC10463173 DOI: 10.1001/jamacardio.2023.3030] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/21/2023] [Indexed: 08/29/2023]
Abstract
Importance Mavacamten has shown clinical benefits in global studies for patients with obstructive hypertrophic cardiomyopathy (oHCM), but evidence in the Asian population is lacking. Objective To evaluate the safety and efficacy of mavacamten compared with placebo for Chinese patients with symptomatic oHCM. Design, Setting, and Participants This phase 3, randomized, double-blind, placebo-controlled clinical trial was conducted at 12 hospitals in China. Between January 4 and August 5, 2022, patients with oHCM and a left ventricular outflow tract (LVOT) gradient of 50 mm Hg or more and New York Heart Association (NYHA) class II or III symptoms were enrolled and received treatment for 30 weeks. Interventions Patients were randomized 2:1 to receive mavacamten (starting at 2.5 mg once daily) or placebo for 30 weeks. Main Outcomes and Measures The primary end point was change in Valsalva LVOT peak gradient from baseline to week 30. Left ventricular outflow tract gradients and left ventricular ejection fraction (LVEF) were assessed by echocardiography, while left ventricular mass index (LVMI) was determined by cardiac magnetic resonance imaging. Analysis was performed on an intention-to-treat basis. Results A total of 81 patients (mean [SD] age, 51.9 [11.9] years; 58 men [71.6%]) were randomized. Mavacamten demonstrated a significant improvement in the primary end point compared with placebo (least-squares mean [LSM] difference, -70.3 mm Hg; 95% CI, -89.6 to -50.9 mm Hg; 1-sided P < .001). Similar trends were demonstrated for resting LVOT peak gradient (LSM difference, -55.0 mm Hg; 95% CI, -69.1 to -40.9 mm Hg). At week 30, more patients receiving mavacamten than placebo achieved a Valsalva LVOT peak gradient less than 30 mm Hg (48.1% [26 of 54] vs 3.7% [1 of 27]), less than 50 mm Hg (59.3% [32 of 54] vs 7.4% [2 of 27]), and NYHA class improvement (59.3% [32 of 54] vs 14.8% [4 of 27]). Greater improvements were also observed with mavacamten regarding the Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (LSM difference, 10.2; 95% CI, 4.4-16.1), N-terminal pro-B-type natriuretic peptide level (proportion of geometric mean ratio, 0.18; 95% CI, 0.13-0.24), high-sensitivity cardiac troponin I level (proportion of geometric mean ratio, 0.34; 95% CI, 0.27-0.42), and LVMI (mean difference, -30.8 g/m2; 95% CI, -41.6 to -20.1 g/m2). Safety and tolerability were similar between mavacamten and placebo. No patients experienced LVEF less than 50%. Conclusions Mavacamten significantly improved Valsalva LVOT gradient vs placebo for Chinese patients. All secondary efficacy end points were also improved. Mavacamten was well tolerated with no new safety signals. This study supports the efficacy and safety of mavacamten in diverse populations, including Chinese patients. Trial Registration ClinicalTrials.gov Identifier: NCT05174416.
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Affiliation(s)
- Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liwen Li
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Xiaoyan Li
- Department of Cardiology, Renmin Hospital of Wuhan University, Hubei General Hospital, Wuhan, Hubei Province, China
| | - Jian’an Wang
- Department of Cardiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Qing Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Zhanquan Li
- Department of Cardiology, the People’s Hospital of Liaoning Province, Shenyang, Liaoning Province, China
| | - Daoquan Peng
- Department of Cardiology, the Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Ping Yang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China
| | - Wei Ma
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Fang Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Jin
- Department of Cardiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiang Cheng
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Jing Sun
- Shanghai LianBio Development Co, Ltd, Shanghai, China
| | - Yiqun Fu
- Shanghai LianBio Development Co, Ltd, Shanghai, China
| | - Cheng Lyu
- Shanghai LianBio Development Co, Ltd, Shanghai, China
| | - Shuyang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Cheung CC, Mori S, Gerstenfeld EP. Iatrogenic Atrioventricular Block. Cardiol Clin 2023; 41:419-428. [PMID: 37321692 DOI: 10.1016/j.ccl.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Iatrogenic atrioventricular (AV) block can occur in the context of cardiac surgery, percutaneous transcatheter, or electrophysiologic procedures. In cardiac surgery, patients undergoing aortic and/or mitral valve surgery are at the highest risk for developing perioperative AV block requiring permanent pacemaker implantation. Similarly, patients undergoing transcatheter aortic valve replacement are also at increased risk for developing AV block. Electrophysiologic procedures, including catheter ablation of AV nodal re-entrant tachycardia, septal accessory pathways, para-Hisian atrial tachycardia, or premature ventricular complexes, are also associated with risk of AV conduction system injury. In this article, we summarize the common causes for iatrogenic AV block, predictors for AV block, and general management considerations.
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Affiliation(s)
- Christopher C Cheung
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco, MU-East 4th Floor, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Center of the Health Science, #46-131, 650 Charles E. Young Drive South, Los Angeles, CA 90095, USA
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco, MU-East 4th Floor, 500 Parnassus Avenue, San Francisco, CA 94143, USA.
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5
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Maron MS, Masri A, Choudhury L, Olivotto I, Saberi S, Wang A, Garcia-Pavia P, Lakdawala NK, Nagueh SF, Rader F, Tower-Rader A, Turer AT, Coats C, Fifer MA, Owens A, Solomon SD, Watkins H, Barriales-Villa R, Kramer CM, Wong TC, Paige SL, Heitner SB, Kupfer S, Malik FI, Meng L, Wohltman A, Abraham T. Phase 2 Study of Aficamten in Patients With Obstructive Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2023; 81:34-45. [PMID: 36599608 DOI: 10.1016/j.jacc.2022.10.020] [Citation(s) in RCA: 52] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/12/2022] [Accepted: 10/12/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Left ventricular outflow tract (LVOT) obstruction is a major determinant of heart failure symptoms in obstructive hypertrophic cardiomyopathy (oHCM). Aficamten, a next-in-class cardiac myosin inhibitor, may lower gradients and improve symptoms in these patients. OBJECTIVES This study aims to evaluate the safety and efficacy of aficamten in patients with oHCM. METHODS Patients with oHCM and LVOT gradients ≥30 mm Hg at rest or ≥50 mm Hg with Valsalva were randomized 2:1 to receive aficamten (n = 28) or placebo (n = 13) in 2 dose-finding cohorts. Doses were titrated based on gradients and ejection fraction (EF). Safety and changes in gradient, EF, New York Heart Association functional class, and cardiac biomarkers were assessed over a 10-week treatment period and after a 2-week washout. RESULTS From baseline to 10 weeks, aficamten reduced gradients at rest (mean difference: -40 ± 27 mm Hg, and -43 ± 37 mm Hg in Cohorts 1 and 2, P = 0.0003 and P = 0.0004 vs placebo, respectively) and with Valsalva (-36 ± 27 mm Hg and -53 ± 44 mm Hg, P = 0.001 and <0.0001 vs placebo, respectively). There were modest reductions in EF (-6% ± 7.5% and -12% ± 5.9%, P = 0.007 and P < 0.0001 vs placebo, respectively). Symptomatic improvement in ≥1 New York Heart Association functional class was observed in 31% on placebo, and 43% and 64% on aficamten in Cohorts 1 and 2, respectively (nonsignificant). With aficamten, N-terminal pro-B-type natriuretic peptide was reduced (62% relative to placebo, P = 0.0002). There were no treatment interruptions and adverse events were similar between treatment arms. CONCLUSIONS Aficamten resulted in substantial reductions in LVOT gradients with most patients experiencing improvement in biomarkers and symptoms. These results highlight the potential of sarcomere-targeted therapy for treatment of oHCM.
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Affiliation(s)
- Martin S Maron
- Lahey Hospital and Medical Center, Burlington, Massachusetts, USA.
| | - Ahmad Masri
- Oregon Health & Science University, Portland, Oregon, USA
| | | | | | - Sara Saberi
- University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Andrew Wang
- Duke University Hospital, Durham, North Carolina, USA
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro de Majadahonda, IDIPHISA, CIBERCV, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | | | - Sherif F Nagueh
- Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Florian Rader
- Cedars Sinai Medical Center, Los Angeles, California, USA
| | | | | | | | | | - Anjali Owens
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | | | | | | | - Timothy C Wong
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sharon L Paige
- Cytokinetics Incorporated, South San Francisco, California, USA
| | | | - Stuart Kupfer
- Cytokinetics Incorporated, South San Francisco, California, USA
| | - Fady I Malik
- Cytokinetics Incorporated, South San Francisco, California, USA
| | - Lisa Meng
- Cytokinetics Incorporated, South San Francisco, California, USA
| | - Amy Wohltman
- Cytokinetics Incorporated, South San Francisco, California, USA
| | - Theodore Abraham
- University of California, San Francisco, San Francisco, California, USA
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Sorajja P, Fraser R, Steffen R, Harris KM. Alcohol Septal Ablation for Obstructive Hypertrophic Cardiomyopathy. Interv Cardiol Clin 2022; 11:245-255. [PMID: 35710280 DOI: 10.1016/j.iccl.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Over the past several decades, alcohol septal ablation has become an established therapy for selected patients, in whom there is clinical improvement in symptoms as well as objective functional capacity. Patient selection is essential to success, with continued emphasis on the procedure being performed by experienced operators as part of a multidisciplinary team. In many patients, the outcomes of alcohol septal ablation are comparable to the standard of surgical myectomy. The optimization of the outcomes of alcohol septal ablation is essential for the longitudinal care of patients with hypertrophic cardiomyopathy.
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Affiliation(s)
- Paul Sorajja
- Center for Valve and Structural Heart Disease, Minneapolis Heart Institute at Abbott Northwestern Hospital, 920 East, 28th Street, Minneapolis, MN 55417, USA; Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55401, USA; Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, 920 East, 28th Street, Minneapolis, MN 55417, USA.
| | - Robert Fraser
- Center for Valve and Structural Heart Disease, Minneapolis Heart Institute at Abbott Northwestern Hospital, 920 East, 28th Street, Minneapolis, MN 55417, USA; Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, 920 East, 28th Street, Minneapolis, MN 55417, USA
| | - Robert Steffen
- Center for Valve and Structural Heart Disease, Minneapolis Heart Institute at Abbott Northwestern Hospital, 920 East, 28th Street, Minneapolis, MN 55417, USA; Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, 920 East, 28th Street, Minneapolis, MN 55417, USA
| | - Kevin M Harris
- Center for Valve and Structural Heart Disease, Minneapolis Heart Institute at Abbott Northwestern Hospital, 920 East, 28th Street, Minneapolis, MN 55417, USA; Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, 920 East, 28th Street, Minneapolis, MN 55417, USA
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7
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Abstract
Iatrogenic atrioventricular (AV) block can occur in the context of cardiac surgery, percutaneous transcatheter, or electrophysiologic procedures. In cardiac surgery, patients undergoing aortic and/or mitral valve surgery are at the highest risk for developing perioperative AV block requiring permanent pacemaker implantation. Similarly, patients undergoing transcatheter aortic valve replacement are also at increased risk for developing AV block. Electrophysiologic procedures, including catheter ablation of AV nodal re-entrant tachycardia, septal accessory pathways, para-Hisian atrial tachycardia, or premature ventricular complexes, are also associated with risk of AV conduction system injury. In this article, we summarize the common causes for iatrogenic AV block, predictors for AV block, and general management considerations.
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Affiliation(s)
- Christopher C Cheung
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco, MU-East 4th Floor, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Center of the Health Science, #46-131, 650 Charles E. Young Drive South, Los Angeles, CA 90095, USA
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco, MU-East 4th Floor, 500 Parnassus Avenue, San Francisco, CA 94143, USA.
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8
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Ghavidel AA, Alizadehasl A, Khalilipur E, Amirghofran A, Nezhadbahram H, Azarfarin R. Surgical Septal Myectomy for Hypertrophic cardiomyopathy. The Iranian Experience. Asian Cardiovasc Thorac Ann 2021; 30:64-73. [PMID: 34605707 DOI: 10.1177/02184923211044582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Hypertrophic obstructive cardiomyopathy (HOCM) is a hereditary heart muscle disorder characterized by significant myocardial hypertrophy. we assessed perioperative and long-term follow-up data of Iranian HOCM patients who underwent SM in 2 pioneering centers. METHODS Clinical data of patients with HOCM septal myectomy are collected. Thirty-day outcome and long-term follow-up data for recurrence of gradient and mortality are reported. RESULTS Ninety-six patients in two different centers enrolled in the study. Most patients of 52 patients in center 1 were male (34/52 [65.3%]).and the mean age was of 36.7 ± 19 years. Syncope before admission was reported in 5.7%, the mean left ventricular ejection fraction on admission was 53 ± 8%, the mean left ventricular outflow tract gradient was 66.3 ± 20.4 mm Hg, and the mean preoperativeseptal thickness was 25.4 ± 6.7 mm. A redo SM was performed in 3 patients (5.8%), mitral valve repair in 5 patients (9.6%), and atrioventricular repair in 5 patients (9.6%). A residual systolic anterior motion was detected in 4 patients (7.7%), the mean postoperative septal thickness was 19 ± 6 mm (25.1% septal thickness reduction), and in-hospital mortality was 5.8% (n = 3). A longer-term follow-up showed death in 3 patients (5.8%) and late recurrent left ventricular outflow tract obstruction in 1 patient. CONCLUSIONS Transaortic myectomy is an effective surgery with acceptable early and late mortality rates. Improvements in functional status are seen in almost all patients. Appropriate SM is crucial to a good clinical outcome. Long-term survival is excellent and cardiac sudden death is extremely rare after a good surgical treatment.
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Affiliation(s)
- Alireza Alizadeh Ghavidel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical & Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azin Alizadehasl
- Department and Research Center of Cardio-Oncology, Rajaie Cardiovascular Medical & Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ehsan Khalilipur
- Cardiovascular intervention Research Center, 158776Rajaie Cardiovascular Medical & Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ahmadali Amirghofran
- Department of Cardiac Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hanieh Nezhadbahram
- Interventional cardiologist, Rajaie Cardiovascular Medical & Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Rasoul Azarfarin
- Cardio- Oncology Research Centre, Rajaie Cardiovascular Medical and Research Centre, Iran University of Medical Sciences, Tehran, Iran
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9
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Vermaete I, Dujardin K, Stammen F. Looking back on 15 years of ultrasound-guided alcohol septal ablation for hypertrophic obstructive cardiomyopathy. Acta Cardiol 2020; 75:483-491. [PMID: 31204591 DOI: 10.1080/00015385.2019.1626550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Septal reduction remains an important target of current therapeutic modalities in hypertrophic obstructive cardiomyopathy (HOCM). Surgical septal myectomy has long been considered the gold standard in pharmacotherapy-refractory severely symptomatic patients with marked left ventricular outflow tract (LVOT) obstruction. In recent years, percutaneous alcohol septal ablation (ASA) has matured into the preferred strategy for patients with favourable anatomy and no other coexisting surgically amenable disease.Methods: We discuss 26 HOCM patients with persistent dyspnoea, angina or syncope despite optimal medical treatment. Baseline septal wall thickness was 20 ± 3 mm, with peak resting/provoked LVOT gradients of 53 ± 35/112 ± 40 mmHg. Guided by echocardiography, alcohol injection could be restricted to the first septal coronary artery in 85% of patients, provoking basal septal infarction with average troponin rise of 3.0 ng/ml.Results: Eighty-six per cent of patients experienced sustained clinical improvement, associated with a reduction of septal wall thickness to 15 ± 3 mm and resting LVOT gradient to 21 ± 15 mmHg. One of the two non-responders underwent additional septal myectomy 11 years after ASA. Notable adverse events during the follow-up of 7.2 ± 4.7 years included: persistent conduction disturbances (65%) necessitating early postprocedural permanent pacemaker implantation (15%); atrial fibrillation (32%); ventricular tachycardia (4%) and aortic stenosis (14%). Six patients died, of which only 1 cardiac death.Conclusions: Our case series underscores the efficacy of ASA at relieving LVOT obstruction and improving symptoms in properly selected HOCM patients, with acceptably low procedural and long term mortality and morbidity.
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Affiliation(s)
- I. Vermaete
- Department of Cardiology, UZ Leuven, Leuven, Belgium
| | - K. Dujardin
- Department of Cardiology, AZ Delta, Roeselare, Belgium
| | - F. Stammen
- Department of Cardiology, AZ Delta, Roeselare, Belgium
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Effects of surgical septal myectomy on survival in patients with hypertrophic obstructive cardiomyopathy. Anatol J Cardiol 2020; 23:342-348. [PMID: 32478684 PMCID: PMC7414245 DOI: 10.14744/anatoljcardiol.2020.05043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective: The purpose of this study was to determine the effects of surgical resection of muscle layer on the long-term survival of patients with hypertrophic obstructive cardiomyopathy (HOCM). Methods: The original study cohort consisted of 552 patients with hypertrophic cardiomyopathy (HCM), including 380 patients with HOCM and 172 patients with nonobstructive HCM. All these patients had a definite diagnosis in our center from October 1, 2009, to December 31, 2012. They were divided into three groups, viz., HOCM with myectomy group (n=194), nonoperated HOCM group (n=186), and nonobstructive HCM group (n=172). Median follow-up duration was 57.57±13.71 months, and the primary end point was a combination of mortality from all causes. Results: In this survival study, we compared the prognoses of patients with HOCM after myectomy, patients with nonoperated HOCM, and patients with nonobstructive HCM. Among the three groups, the myectomy group showed a lower rate of reaching the all-cause mortality with statistically indistinguishable overall survival compared with patients with nonobstructive HCM (p=0.514). Among patients with left ventricular outflow tract (LVOT) obstruction, the overall survival in the myectomy group was noticeably better than that in the nonoperated HOCM group (log-rank p<0.001). Parameters that showed a significant univariate correlation with survival included age, previous atrial fibrillation (AF), NT-proBNP, Cr, myectomy, and LV ejection fraction. When these variables were entered in the multivariate model, the only independent predictors of survival were myotomy [hazard ratio (HR): 0.109; 95% CI: 0.013–0.877, p<0.037], age (HR: 1.047; 95% CI: 1.007–1.088, p=0.021), and previous AF (HR: 2.659; 95% CI: 1.022–6.919, p=0.021). Conclusion: Patients with HOCM undergoing myectomy appeared to suffer from a lower risk of reaching the all-cause mortality and demonstrated statistically indistinguishable overall survival compared with patients with nonobstructive HCM. Multivariate analysis clearly demonstrated myectomy as a powerful, independent factor of survival, confirming that the differences in long-term survival recorded in this study may be due to surgical improvement in the LVOT gradient.
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Smith JR, Layrisse V, Medina-Inojosa JR, Berg JD, Ommen SR, Olson TP. Predictors of exercise capacity following septal myectomy in patients with hypertrophic cardiomyopathy. Eur J Prev Cardiol 2020; 27:1066-1073. [PMID: 31967491 DOI: 10.1177/2047487319898106] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
AIMS Patients with hypertrophic obstructive cardiomyopathy (HOCM) have impaired exercise capacity. The gold standard therapy for patients with HOCM is septal myectomy surgery; however, changes in maximum oxygen uptake (VO2peak) following myectomy are variable, with VO2peak decreasing in some patients. Therefore, we evaluated changes in VO2peak following surgical myectomy to determine clinical predictors of those exhibiting decreased VO2peak post-myectomy. METHODS HOCM patients (N = 295) who performed symptom limited cardiopulmonary exercise testing prior to and following surgical myectomy were included for analysis. The VO2peak non-responder group (n = 128) was defined as <0% change in VO2peak from pre- to post-myectomy. Step-wise regression models using demographics, clinical, and physiologic characteristics were created to determine predictors of hypertrophic cardiomyopathy patients in the VO2peak non-responder group. RESULTS Independent predictors of the VO2peak non-responder group included higher pre-myectomy VO2peak (% predicted), older age, women, history of dyslipidemia, lack of cardiac rehabilitation enrollment, and lower body mass index (all p < 0.03). Forty-three (14.6%) patients reached the primary end-point of all-cause mortality during a median follow up of 11.25 years (interquartile range 6.94 to 16.40). After adjustment for age, sex, beta-blocker use, coronary artery disease history, and body mass index, the VO2peak non-responder group had greater risk of death compared with the VO2peak responder group (adjusted hazard ratio: 1.77, 95% confidence interval: 1.06-3.34, p = 0.01). CONCLUSION This large hypertrophic cardiomyopathy cohort demonstrated that demographic (i.e. female sex), lack of cardiac rehabilitation enrollment, and cardiovascular risk factors (i.e. history of dyslipidemia) are predictive of those patients that did not exhibit increases in VO2peak following septal myectomy surgery.
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Affiliation(s)
- Joshua R Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, USA
| | - Veronica Layrisse
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, USA.,San Juan Bautista School of Medicine, Caguas, Puerto Rico
| | | | - Jessica D Berg
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, USA
| | - Steve R Ommen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, USA
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, USA
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13
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Nguyen A, Schaff HV, Hang D, Nishimura RA, Geske JB, Dearani JA, Lahr BD, Ommen SR. Surgical myectomy versus alcohol septal ablation for obstructive hypertrophic cardiomyopathy: A propensity score–matched cohort. J Thorac Cardiovasc Surg 2019; 157:306-315.e3. [DOI: 10.1016/j.jtcvs.2018.08.062] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/20/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
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Hang D, Schaff HV, Ommen SR, Dearani JA, Nishimura RA. Combined transaortic and transapical approach to septal myectomy in patients with complex hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg 2018; 155:2096-2102. [DOI: 10.1016/j.jtcvs.2017.10.054] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 07/07/2017] [Accepted: 10/02/2017] [Indexed: 10/18/2022]
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15
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Risk marker profiles in patients treated with percutaneous septal ablation for symptomatic hypertrophic obstructive cardiomyopathy. Clin Res Cardiol 2018; 107:479-486. [DOI: 10.1007/s00392-018-1209-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 01/31/2018] [Indexed: 11/26/2022]
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16
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Price J, Clarke N, Turer A, Quintana E, Mestres C, Huffman L, Peltz M, Wait M, Ring WS, Jessen M, Bajona P. Hypertrophic obstructive cardiomyopathy: review of surgical treatment. Asian Cardiovasc Thorac Ann 2017; 25:594-607. [PMID: 28901158 DOI: 10.1177/0218492317733111] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hypertrophic cardiomyopathy ranks among the most common congenital cardiac diseases, affecting up to 1 in 200 of the general population. When it causes left ventricular outflow tract obstruction, treatment is guided to reduce symptoms and the risk of sudden cardiac death. Pharmacologic therapy is the first-line treatment, but when it fails, surgical myectomy or percutaneous ablation of the hypertrophic myocardium are the standard therapies to eliminate subaortic obstruction. Both surgical myectomy and percutaneous ablation are proven safe and effective treatments; however, myectomy is the gold standard with a significantly lower complication rate and more complete and lasting reduction of left ventricular outflow tract obstruction.
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Affiliation(s)
- Jonathan Price
- 1 Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicholas Clarke
- 1 Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Aslan Turer
- 2 Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Eduard Quintana
- 3 Hospital Clínic de Barcelona, Cardiovascular Surgery Department, Cardiovascular Institute, University of Barcelona Medical School, Barcelona, Spain
| | - Carlos Mestres
- 4 Department of Cardiovascular Surgery, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Lynn Huffman
- 1 Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthias Peltz
- 1 Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Michael Wait
- 1 Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - W Steves Ring
- 1 Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Michael Jessen
- 1 Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Pietro Bajona
- 1 Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,5 Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
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Poon SS, Field M, Gupta D, Cameron D. Surgical septal myectomy or alcohol septal ablation: which approach offers better outcomes for patients with hypertrophic obstructive cardiomyopathy? Interact Cardiovasc Thorac Surg 2017; 24:951-961. [DOI: 10.1093/icvts/ivx001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 01/02/2017] [Indexed: 11/12/2022] Open
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Choudhury L, Rigolin VH, Bonow RO. Integrated Imaging in Hypertrophic Cardiomyopathy. Am J Cardiol 2017; 119:328-339. [PMID: 27816114 DOI: 10.1016/j.amjcard.2016.09.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/27/2016] [Accepted: 09/27/2016] [Indexed: 11/27/2022]
Abstract
Hypertrophic cardiomyopathy (HC) has a very heterogeneous clinical spectrum and lends itself to multimodality imaging for evaluation and management. This review addresses clinical applications of cardiac imaging in patients with HC. Integrating various techniques of echocardiography and cardiac magnetic resonance (CMR) is discussed in the clinical context such as diagnosis, evaluation, management, risk stratification, and family screening of patients with HC. The utility of periprocedural imaging techniques is highlighted for guiding surgical and transcatheter septal reduction procedures. More limited roles of invasive or computed tomography coronary angiography are discussed for patients with HC with chest pain and risk factors for coronary artery disease. Nuclear techniques although available for decades play a more limited role in contemporary routine management but may assist in risk assessment. Newer CMR and echo imaging techniques are discussed in their emerging roles for further characterization of patients with HC and family members with prospects of preclinical diagnosis. The strengths of the different imaging modalities are presented as well as a flow diagram summarizing integrated imaging in this disease. In conclusion, integrated imaging using the various imaging techniques predominantly echocardiography and CMR based on the clinical picture plays an essential role in the management of patients with HC.
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Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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20
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Sedehi D, Finocchiaro G, Tibayan Y, Chi J, Pavlovic A, Kim YM, Tibayan FA, Reitz BA, Robbins RC, Woo J, Ha R, Lee DP, Ashley EA. Long-term outcomes of septal reduction for obstructive hypertrophic cardiomyopathy. J Cardiol 2015; 66:57-62. [DOI: 10.1016/j.jjcc.2014.08.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 07/16/2014] [Accepted: 08/14/2014] [Indexed: 11/15/2022]
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Quintana E, Sabate-Rotes A, Maleszewski JJ, Ommen SR, Nishimura RA, Dearani JA, Schaff HV. Septal myectomy after failed alcohol ablation: Does previous percutaneous intervention compromise outcomes of myectomy? J Thorac Cardiovasc Surg 2015; 150:159-67.e1. [DOI: 10.1016/j.jtcvs.2015.03.044] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 03/18/2015] [Accepted: 03/26/2015] [Indexed: 10/23/2022]
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SCHULLER JOSEPHL, ZIPSE MATTHEWM, KRANTZ MORIJ, BLAKER BRIAN, SALCEDO ERNESTO, GROVES BERTRONM, MESSENGER JOHNC, BEATY BRENDA, SAUER WILLIAMH. Incidence and Predictors of Late Complete Heart Block After Alcohol Septal Ablation Treatment of Hypertrophic Obstructive Cardiomyopathy. J Interv Cardiol 2015; 28:90-7. [DOI: 10.1111/joic.12178] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- JOSEPH L. SCHULLER
- Cardiology Division; Denver Health; Denver Colorado
- University of Colorado School of Medicine; Aurora Colorado
| | | | - MORI J. KRANTZ
- Cardiology Division; Denver Health; Denver Colorado
- University of Colorado School of Medicine; Aurora Colorado
| | - BRIAN BLAKER
- Cardiology Division; Denver Health; Denver Colorado
| | | | | | | | - BRENDA BEATY
- University of Colorado School of Medicine; Aurora Colorado
- Colorado Health Outcomes Program; Aurora Colorado
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Noble S, Sigwart U. Therapeutic management of hypertrophic obstructive cardiomyopathy: alcohol septal ablation or surgical myomectomy? Expert Rev Cardiovasc Ther 2014; 12:1041-4. [DOI: 10.1586/14779072.2014.942287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Angiographic and echocardiographic correlates of suitable septal perforators for alcohol septal ablation in hypertrophic obstructive cardiomyopathy. Can J Cardiol 2014; 30:912-9. [PMID: 25064582 DOI: 10.1016/j.cjca.2014.04.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 03/29/2014] [Accepted: 04/03/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Myocardial contrast echocardiography during angiography is critical in identifying appropriate septal perforator(s) for alcohol septal ablation (ASA) in patients with hypertrophic obstructive cardiomyopathy. We evaluated whether there were other angiographic and/or echocardiographic markers that might identify patients who are anatomically suitable for ASA. METHODS We performed quantitative coronary angiographic analysis and echocardiographic assessment on 74 patients referred for ASA from January 2004 to July 2012 at the Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada. Patients who proceeded to ASA were compared with those in whom ASA was aborted. RESULTS Of the 74 patients referred for ASA, 63 proceeded to ASA and in 11 patients ASA was aborted because of various anatomic and technical reasons. There were no clinically significant differences observed in quantitative angiographic and echocardiographic measurements between the 2 groups. The ratio of ostial left main (LM) to ablated septal distance on angiography vs the basal septum to the septum area where the mitral valve contacted the septum because of systolic anterior motion (SAM) was 1.53. In the whole cohort, a significant correlation was observed between the ostial LM to the target septal distance and the distance from basal septum to SAM-septal contact point on echocardiography (r = 0.39; P = 0.008). A stronger correlation was evident when analysis was restricted to patients undergoing ASA only (r = 0.44; P = 0.006). CONCLUSIONS Echocardiographic and angiographic assessments of the distance between the basal septum to SAM-septal contact point and ostial LM to the target septal distance might be useful in preprocedural selection of the appropriate septal perforator for ASA.
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Geske JB, Klarich KW, Ommen SR, Schaff HV, Nishimura RA. Septal reduction therapies in hypertrophic cardiomyopathy: comparison of surgical septal myectomy and alcohol septal ablation. Interv Cardiol 2014. [DOI: 10.2217/ica.14.8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Báez-Escudero JL, Keida T, Dave AS, Okishige K, Valderrábano M. Ethanol infusion in the vein of Marshall leads to parasympathetic denervation of the human left atrium: implications for atrial fibrillation. J Am Coll Cardiol 2014; 63:1892-901. [PMID: 24561151 DOI: 10.1016/j.jacc.2014.01.032] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 12/18/2013] [Accepted: 01/07/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study sought to determine whether ethanol infusion in the vein of Marshall (VOM) can ablate intrinsic cardiac nerves (ICN). BACKGROUND ICN cluster around the left atrial epicardium and are implicated in the genesis of atrial fibrillation (AF). METHODS Patients undergoing catheter AF ablation underwent adjunctive ethanol injection in the VOM. A multipolar catheter was introduced in the VOM and used for high-frequency stimulation (HFS), either as HFS with P-wave synchronized (SynchHFS), 30 pulses, 100 Hz (n = 8) or as HFS with 3 to 10 s bursts (BurstHFS), 33 Hz (n = 72) at 25 mA for 1-ms duration. Atrioventricular (AV) nodal conduction slowing (asystole >2 s or R-R interval prolongation >50%) and AF inducibility were assessed before and after VOM ethanol infusion. Up to 4 1-ml infusions of 98% ethanol were delivered via an angioplasty balloon in the VOM. RESULTS SynchHFS induced AF in 8 of 8 patients. In 4 of 8 AF initiated spontaneously without VOM capture. No parasympathetic responses were elicited by SynchHFS. BurstHFS was performed in 32 patients undergoing de novo AF ablation (Group 1) and 40 patients undergoing repeat ablation (Group 2). Parasympathetic responses were found in all 32 Group 1 patients and in 75% of Group 2 patients. After VOM ethanol infusion, parasympathetic responses were abolished in all patients (both groups). There were no acute complications related to VOM ethanol infusion. CONCLUSIONS The VOM contains ICN that connect with the AV node and can trigger AF. Retrograde ethanol infusion in the VOM reliably eliminates local ICN responses. The VOM is a vascular route for ICN-targeting therapies.
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Affiliation(s)
- José L Báez-Escudero
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas
| | - Takehiko Keida
- Department of Cardiology, Edogawa Hospital, Tokyo, Japan
| | - Amish S Dave
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas
| | | | - Miguel Valderrábano
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas.
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Sathyamurthy I, Nayak R, Oomman A, Subramanyan K, Kalarical MS, Mao R, Ramachandran P. Alcohol septal ablation for hypertrophic obstructive cardiomyopathy - 8 years follow up. Indian Heart J 2013; 66:57-63. [PMID: 24581097 PMCID: PMC5125590 DOI: 10.1016/j.ihj.2013.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 11/18/2013] [Accepted: 12/04/2013] [Indexed: 11/30/2022] Open
Abstract
Background Alcohol septal ablation is emerging as an alternative to surgical myectomy in the management of symptomatic cases of Hypertrophic obstructive cardiomyopathy (HOCM). This involves injection of absolute alcohol into 1st septal perforator thereby producing myocardial necrosis with resultant septal remodelling within 3–6 months. This results in reduction of septal thickness and LV outflow gradients with improvement in symptoms. Methods Fifty three patients had undergone alcohol septal ablation, there were 2 early and 2 late deaths and 4 patients lost to follow up. Forty-five (85%) of them were followed up to a mean period of 96 ± 9.2 months. Clinical, ECG, and Echocardiographic parameters were evaluated during follow up. Results Only 4 out of 51 patients remained in NYHA class III or IV at the end of 6 months. Significant reduction of LV outflow gradients (79 ± 35 to 34 ± 23 mmHg) and septal thickness (23 ± 4.7 mm to 19 ± 3 mm) were observed during 6 months follow up. Beyond 6 months there was no further decrease in either septal thickness or LVOT gradients noted. Ten percent of patients needed pacemaker implantation. There was 92% survival at the end of 8 years. Conclusion Alcohol septal ablation is a safe and effective nonsurgical procedure for the treatment of HOCM. By minimizing the amount of alcohol to ≤2 ml, one can reduce complications and mortality. The long-term survival is gratifying.
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Affiliation(s)
- I Sathyamurthy
- Sr. Interventional Cardiologist & Director, Dept of Cardiology, Apollo Hospitals, Chennai 600006, India.
| | - Rajeshwari Nayak
- Sr. Interventional Cardiologist, Apollo Hospitals, Chennai 600006, India
| | - Abraham Oomman
- Sr. Interventional Cardiologist, Apollo Hospitals, Chennai 600006, India
| | - K Subramanyan
- Sr. Interventional Cardiologist, Apollo Hospitals, Chennai 600006, India
| | | | - Robert Mao
- Sr. Interventional Cardiologist, Apollo Hospitals, Chennai 600006, India
| | - P Ramachandran
- Sr. Interventional Cardiologist, Apollo Hospitals, Chennai 600006, India
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Cieslik KA, Trial J, Crawford JR, Taffet GE, Entman ML. Adverse fibrosis in the aging heart depends on signaling between myeloid and mesenchymal cells; role of inflammatory fibroblasts. J Mol Cell Cardiol 2013; 70:56-63. [PMID: 24184998 DOI: 10.1016/j.yjmcc.2013.10.017] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/02/2013] [Accepted: 10/22/2013] [Indexed: 11/18/2022]
Abstract
Aging has been associated with adverse fibrosis. Here we formulate a new hypothesis and present new evidence that unresponsiveness of mesenchymal stem cells (MSC) and fibroblasts to transforming growth factor beta (TGF-β), due to reduced expression of TGF-β receptor I (TβRI), provides a foundation for cardiac fibrosis in the aging heart via two mechanisms. 1) TGF-β promotes expression of Nanog, a transcription factor that retains MSC in a primitive state. In MSC derived from the aging heart, Nanog expression is reduced and therefore MSC gradually differentiate and the number of mesenchymal fibroblasts expressing collagen increases. 2) As TGF-β signaling pathway components negatively regulate transcription of monocyte chemoattractant protein-1 (MCP-1), a reduced expression of TβRI prevents aging mesenchymal cells from shutting down their own MCP-1 expression. Elevated MCP-1 levels that originated from MSC attract transendothelial migration of mononuclear leukocytes from blood to the tissue. MCP-1 expressed by mesenchymal fibroblasts promotes further migration of monocytes and T lymphocytes away from the endothelial barrier and supports the monocyte transition into macrophages and finally into myeloid fibroblasts. Both myeloid and mesenchymal fibroblasts contribute to fibrosis in the aging heart via collagen synthesis. This article is part of a Special Issue entitled "Myocyte-Fibroblast Signalling in Myocardium ".
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Affiliation(s)
- Katarzyna A Cieslik
- Division of Cardiovascular Sciences and the DeBakey Heart Center, Department of Medicine, Baylor College of Medicine, and Houston Methodist, Houston, TX 77030, USA.
| | - JoAnn Trial
- Division of Cardiovascular Sciences and the DeBakey Heart Center, Department of Medicine, Baylor College of Medicine, and Houston Methodist, Houston, TX 77030, USA
| | - Jeffrey R Crawford
- Division of Cardiovascular Sciences and the DeBakey Heart Center, Department of Medicine, Baylor College of Medicine, and Houston Methodist, Houston, TX 77030, USA
| | - George E Taffet
- Division of Cardiovascular Sciences and the DeBakey Heart Center, Department of Medicine, Baylor College of Medicine, and Houston Methodist, Houston, TX 77030, USA
| | - Mark L Entman
- Division of Cardiovascular Sciences and the DeBakey Heart Center, Department of Medicine, Baylor College of Medicine, and Houston Methodist, Houston, TX 77030, USA.
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Bartels K, Daneshmand MA, Mathew JP, Glower DD, Swaminathan M, Nicoara A. Delayed postmyectomy ventricular septal defect. J Cardiothorac Vasc Anesth 2013; 27:381-4. [PMID: 23507017 DOI: 10.1053/j.jvca.2012.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Karsten Bartels
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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Cooper RM, Shahzad A, Stables RH. Current status of nonsurgical septal reduction therapy in hypertrophic obstructive cardiomyopathy. Interv Cardiol 2013. [DOI: 10.2217/ica.13.33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
Hypertrophic cardiomyopathy is a common inherited cardiovascular disease present in one in 500 of the general population. It is caused by more than 1400 mutations in 11 or more genes encoding proteins of the cardiac sarcomere. Although hypertrophic cardiomyopathy is the most frequent cause of sudden death in young people (including trained athletes), and can lead to functional disability from heart failure and stroke, the majority of affected individuals probably remain undiagnosed and many do not experience greatly reduced life expectancy or substantial symptoms. Clinical diagnosis is based on otherwise unexplained left-ventricular hypertrophy identified by echocardiography or cardiovascular MRI. While presenting with a heterogeneous clinical profile and complex pathophysiology, effective treatment strategies are available, including implantable defibrillators to prevent sudden death, drugs and surgical myectomy (or, alternatively, alcohol septal ablation) for relief of outflow obstruction and symptoms of heart failure, and pharmacological strategies (and possibly radiofrequency ablation) to control atrial fibrillation and prevent embolic stroke. A subgroup of patients with genetic mutations but without left-ventricular hypertrophy has emerged, with unresolved natural history. Now, after more than 50 years, hypertrophic cardiomyopathy has been transformed from a rare and largely untreatable disorder to a common genetic disease with management strategies that permit realistic aspirations for restored quality of life and advanced longevity.
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Affiliation(s)
- Barry J Maron
- The Hypertrophic Cardiomyopathy Centers of Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
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Sorajja P, Ommen SR, Holmes DR, Dearani JA, Rihal CS, Gersh BJ, Lennon RJ, Nishimura RA. Survival After Alcohol Septal Ablation for Obstructive Hypertrophic Cardiomyopathy. Circulation 2012; 126:2374-80. [DOI: 10.1161/circulationaha.111.076257] [Citation(s) in RCA: 205] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The clinical efficacy of alcohol septal ablation for obstructive hypertrophic cardiomyopathy (HCM) has been demonstrated, but the long-term effects of the procedure remain uncertain. This study examined the survival of patients after septal ablation performed in a tertiary HCM referral center.
Methods and Results—
We examined 177 patients (mean age, 64 years; 68% women) who underwent septal ablation at our institution. Over a follow-up of 5.7 years, survival free of all mortality was no different than the expected survival for a comparable general population, and similar to that of age- and sex-matched patients who underwent isolated surgical myectomy (8-year survival estimate, 79% versus 79%;
P
=0.64). For the end point of documented sudden cardiac death or unknown cause of death, the incidence per 100 person-year follow-up was 1.31 (95% confidence interval, 0.60–2.38). Residual left ventricular outflow tract gradient after ablation was an independent predictor of long-term survival free of any death.
Conclusions—
In this nonrandomized study of carefully selected patients undergoing septal ablation by experienced operators in a tertiary referral HCM center, long-term survival was favorable and similar to that of an age- and sex-matched general population, and to patients undergoing surgical myectomy, as well, without an increased risk of sudden cardiac death.
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Affiliation(s)
- Paul Sorajja
- From the Division of Cardiovascular Diseases and Internal Medicine (P.S., S.R.O., D.R.H., C.S.R., B.J.G., R.A.N.), Department of Biomedical Statistics and Informatics (R.J.L.), and Division of Cardiovascular Surgery (J.A.D.), Mayo Clinic, Rochester, MN
| | - Steve R. Ommen
- From the Division of Cardiovascular Diseases and Internal Medicine (P.S., S.R.O., D.R.H., C.S.R., B.J.G., R.A.N.), Department of Biomedical Statistics and Informatics (R.J.L.), and Division of Cardiovascular Surgery (J.A.D.), Mayo Clinic, Rochester, MN
| | - David R. Holmes
- From the Division of Cardiovascular Diseases and Internal Medicine (P.S., S.R.O., D.R.H., C.S.R., B.J.G., R.A.N.), Department of Biomedical Statistics and Informatics (R.J.L.), and Division of Cardiovascular Surgery (J.A.D.), Mayo Clinic, Rochester, MN
| | - Joseph A. Dearani
- From the Division of Cardiovascular Diseases and Internal Medicine (P.S., S.R.O., D.R.H., C.S.R., B.J.G., R.A.N.), Department of Biomedical Statistics and Informatics (R.J.L.), and Division of Cardiovascular Surgery (J.A.D.), Mayo Clinic, Rochester, MN
| | - Charanjit S. Rihal
- From the Division of Cardiovascular Diseases and Internal Medicine (P.S., S.R.O., D.R.H., C.S.R., B.J.G., R.A.N.), Department of Biomedical Statistics and Informatics (R.J.L.), and Division of Cardiovascular Surgery (J.A.D.), Mayo Clinic, Rochester, MN
| | - Bernard J. Gersh
- From the Division of Cardiovascular Diseases and Internal Medicine (P.S., S.R.O., D.R.H., C.S.R., B.J.G., R.A.N.), Department of Biomedical Statistics and Informatics (R.J.L.), and Division of Cardiovascular Surgery (J.A.D.), Mayo Clinic, Rochester, MN
| | - Ryan J. Lennon
- From the Division of Cardiovascular Diseases and Internal Medicine (P.S., S.R.O., D.R.H., C.S.R., B.J.G., R.A.N.), Department of Biomedical Statistics and Informatics (R.J.L.), and Division of Cardiovascular Surgery (J.A.D.), Mayo Clinic, Rochester, MN
| | - Rick A. Nishimura
- From the Division of Cardiovascular Diseases and Internal Medicine (P.S., S.R.O., D.R.H., C.S.R., B.J.G., R.A.N.), Department of Biomedical Statistics and Informatics (R.J.L.), and Division of Cardiovascular Surgery (J.A.D.), Mayo Clinic, Rochester, MN
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Assessment of Left Ventricular Outflow Gradient. JACC Cardiovasc Interv 2012; 5:675-81. [DOI: 10.1016/j.jcin.2012.01.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 01/09/2012] [Accepted: 01/20/2012] [Indexed: 11/23/2022]
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Qintar M, Morad A, Alhawasli H, Shorbaji K, Firwana B, Essali A, Kadro W. Pacing for drug-refractory or drug-intolerant hypertrophic cardiomyopathy. Cochrane Database Syst Rev 2012; 2012:CD008523. [PMID: 22592731 PMCID: PMC8094451 DOI: 10.1002/14651858.cd008523.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is a genetic disease with an autosomal-dominant inheritance for which negative inotropes are the most widely used initial therapies. Observational studies and small randomised trials have suggested symptomatic and functional benefits using pacing and several theories have been put forward to explain why. Pacing, although not the primary treatment for HCM, could be beneficial to patients with relative or absolute contraindications to surgery or alcohol ablation. Several randomised controlled trials comparing pacing to other therapeutic modalities have been conducted but no Cochrane-style systematic review has been done. OBJECTIVES To assess the effects of pacing in drug-refractory or drug-intolerant hypertrophic cardiomyopathy patients. SEARCH METHODS We searched the following on the 14/4/2010: CENTRAL (The Cochrane Library 2010, Issue 1), MEDLINE OVID (from 1950 onwards ), EMBASE OVID (from 1980 onwards ), Web of Science with Conference Proceedings (from 1970 onwards). No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials of either parallel or crossover design that assess the beneficial and harmful effects of pacing for hypertrophic cardiomyopathy were included. When crossover studies were identified, we considered data only from the first phase. DATA COLLECTION AND ANALYSIS Data from included studies were extracted onto a pre-formed data extraction paper by two authors independently. Data was then entered into Review Manager 5.1 for analysis. Risk of bias was assessed using the guidance provided in the Cochrane Handbook. For dichotomous data, relative risk was calculated; and for continuous data, the mean differences were calculated. Where appropriate data were available, meta-analysis was performed. Where meta-analysis was not possible, a narrative synthesis was written. A QUROUM flow chart was provided to show the flow of papers. MAIN RESULTS Five studies (reported in 10 papers) were identified. However, three of the five studies provided un-usable data. Thus the data from only two studies (reported in seven papers) with 105 participants were included for this review. There was insufficient data to compare results on all-cause mortality, cost effectiveness, exercise capacity, Quality of life and Peak O2 consumption.When comparing active pacing versus placebo pacing on exercise capacity, one study showed that exercise time decreased from (13.1 ± 4.4) minutes to (12.6 ± 4.3) minutes in the placebo group and increased from (12.1 ± 5.6) minutes to (12.9 ± 4.2) minutes in the treatment group (MD 0.30; 95% CI -1.54 to 2.14). Statistically significant data from the same study showed that left ventricular outflow tract obstruction decreased from (71 ± 32) mm Hg to (52 ± 34) mm Hg in the placebo group and from (70 ± 24) mm Hg to (33 ± 27) mm Hg in the active pacing group (MD -19.00; 95% CI -32.29 to -5.71). This study was also able to show that New York Heart Association (NYHA) functional class decreased from (2.5 ± 0.5) to (2.2 ± 0.6) in the inactive pacing group and decreased from (2.6 ± 0.5) to (1.7 ± 0.7) in the placebo group (MD -0.50; 95% CI -0.78 to -0.22).When comparing active pacing versus trancoronary ablation of septal hypertrophy (TASH), data from one study showed that NYHA functional class decreased from (3.2 ± 0.7) to (1.5 ± 0.5) in the TASH group and decreased from (3.0 ± 0.1) to (1.9 ± 0.6) in the pacemaker group. This study also showed that LV wall thickness remained unchanged in the active pacing group compared to reduction from (22 ± 4) mm to (17 ± 3) mm in the TASH group (MD 0.60; 95% CI -5.65 to 6.85) and that LV outflow tract obstruction decreased from (80 ± 35.5) mm Hg in the TASH group to (49.3 ± 37.7) mm Hg in the pacemaker group. AUTHORS' CONCLUSIONS Trials published to date lack information on clinically relevant end-points. Existing data is derived from small trials at high risk of bias, which concentrate on physiological measures. Their results are inconclusive. Further large and high quality trials with more appropriate outcomes are warranted.
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Affiliation(s)
- Mohammed Qintar
- Cleveland Clinic, OH, USA, Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic.
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Sorajja P, Binder J, Nishimura RA, Holmes DR, Rihal CS, Gersh BJ, Bresnahan JF, Ommen SR. Predictors of an optimal clinical outcome with alcohol septal ablation for obstructive hypertrophic cardiomyopathy. Catheter Cardiovasc Interv 2012; 81:E58-67. [PMID: 22511295 DOI: 10.1002/ccd.24328] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 01/03/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Alcohol septal ablation has emerged as a therapy for patients with obstructive hypertrophic cardiomyopathy (HCM). However, there are limited data on the predictors of success with the procedure. METHODS We examined patient characteristics and cardiac morphology as well as procedural data on 166 HCM patients (mean age, 63 years; 43% men), who underwent ablation at Mayo Clinic. Patients were contacted to determine vital status and symptoms to assess the primary endpoint of survival free of death and severe symptoms (New York Heart Association, class III or IV dyspnea). RESULTS The strongest patient characteristics that predicted clinical success were older age, less severe left ventricular outflow tract gradient, lesser ventricular septal hypertrophy, and a smaller left anterior descending (LAD) diameter. Mitral valve geometry or ventricular septal morphology did not predict outcome. Patients with ≥3 characteristics (age ≥65 years, gradient <100 mmHg, septal hypertrophy ≤18 mm, LAD diameter <4.0 mm) had superior 4-year survival free of death and severe symptoms (90.4%) in comparison to those with two characteristics (81.6%) and ≤1 characteristic (57.5%). Case volume with >50 patients was an independent predictor of survival free of severe symptoms. The volume of alcohol injected, number of arteries injected, or size of septal perforator artery were not predictive of clinical success. CONCLUSIONS Greater case volume and selection for key patient and anatomic characteristics are associated with superior outcomes with alcohol septal ablation.
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Affiliation(s)
- Paul Sorajja
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
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Ball W, Ivanov J, Rakowski H, Wigle ED, Linghorne M, Ralph-Edwards A, Williams WG, Schwartz L, Guttman A, Woo A. Long-term survival in patients with resting obstructive hypertrophic cardiomyopathy comparison of conservative versus invasive treatment. J Am Coll Cardiol 2012; 58:2313-21. [PMID: 22093509 DOI: 10.1016/j.jacc.2011.08.040] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Revised: 08/10/2011] [Accepted: 08/15/2011] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The aim of this study was to compare the survival of patients with hypertrophic cardiomyopathy (HCM) and resting left ventricular outflow tract (LVOT) obstruction managed with an invasive versus a conservative strategy. BACKGROUND In patients with resting obstructive HCM, clinical benefit can be achieved after invasive septal reduction therapy. However, it remains controversial whether invasive treatment improves long-term survival. METHODS We studied a consecutive cohort of 649 patients with resting obstructive HCM. Total and HCM-related mortality were compared in 246 patients who were conservatively managed with 403 patients who were invasively managed by surgical myectomy, septal ethanol ablation, or dual-chamber pacing. RESULTS Multivariable analyses (with invasive therapy treated as a time-dependent covariate) showed that an invasive intervention was a significant determinant of overall mortality (hazard ratio: 0.6, 95% confidence interval: 0.4 to 0.97, p = 0.04). Overall survival rates were greater in the invasive (99.2% 1-year, 95.7% 5-year, and 87.8% 10-year survival) than in the conservative (97.3% 1-year, 91.1% 5-year, and 75.8% 10-year survival, p = 0.008) cohort. However, invasive therapy was not found to be a significant independent predictor of HCM-related mortality (hazard ratio: 0.7, 95% confidence interval: 0.4 to 1.3, p = 0.3). The HCM-related survival was 99.5% (1 year), 96.3% (5 years), and 90.2% (10 years) in the invasive cohort, and 97.8% (1 year), 94.6% (5 years), and 86.9% (10 years) in the conservative cohort (p = 0.3). CONCLUSIONS Patients treated invasively have an overall survival advantage compared with conservatively treated patients, with the latter group more likely to die from noncardiac causes. The HCM-related mortality is similar, regardless of a conservative versus invasive strategy.
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Affiliation(s)
- Warren Ball
- Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
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Abstract
Hypertrophic cardiomyopathy is a fascinating disease of marked heterogeneity. Hypertrophic cardiomyopathy was originally characterized by massive myocardial hypertrophy in the absence of known etiology, a dynamic left ventricular outflow obstruction, and increased risk of sudden death. It is now well accepted that multiple mutations in genes encoding for the cardiac sarcomere are responsible for the disease. Complex morphologic and pathophysiologic differences, disparate natural history studies, and novel treatment strategies underscore the challenge to the practicing cardiologist when faced with the management of the hypertrophic cardiomyopathy patient.
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW. 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy. Circulation 2011; 124:e783-831. [PMID: 22068434 DOI: 10.1161/cir.0b013e318223e2bd] [Citation(s) in RCA: 505] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Bernard J. Gersh
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- ACCF/AHA Representative
| | - Barry J. Maron
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- ACCF/AHA Representative
| | | | - Joseph A. Dearani
- Society of Thoracic Surgeons Representative
- American Association for Thoracic Surgery Representative
| | - Michael A. Fifer
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- ACCF/AHA Representative
| | - Mark S. Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- Heart Rhythm Society Representative
| | - Srihari S. Naidu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- Society for Cardiovascular Angiography and Interventions Representative
| | | | | | - Harry Rakowski
- ACCF/AHA Representative
- American Society of Echocardiography Representative
| | | | | | - James E. Udelson
- Heart Failure Society of America Representative
- American Society of Nuclear Cardiology Representative
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW, Jacobs AK, Smith SC, Anderson JL, Albert NM, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Krumholz HM, Kushner FG, Nishimura RA, Ohman EM, Page RL, Stevenson WG, Tarkington LG, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg 2011; 142:e153-203. [DOI: 10.1016/j.jtcvs.2011.10.020] [Citation(s) in RCA: 223] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW, Jacobs AK, Smith SC, Anderson JL, Albert NM, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Krumholz HM, Kushner FG, Nishimura RA, Ohman EM, Page RL, Stevenson WG, Tarkington LG, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: Executive summary. J Thorac Cardiovasc Surg 2011; 142:1303-38. [DOI: 10.1016/j.jtcvs.2011.10.019] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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41
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:2761-96. [PMID: 22068435 DOI: 10.1161/cir.0b013e318223e230] [Citation(s) in RCA: 589] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011; 58:2703-38. [PMID: 22075468 DOI: 10.1016/j.jacc.2011.10.825] [Citation(s) in RCA: 196] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e212-60. [PMID: 22075469 DOI: 10.1016/j.jacc.2011.06.011] [Citation(s) in RCA: 820] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Alcohol Septal Ablation for the Treatment of Hypertrophic Obstructive Cardiomyopathy. J Am Coll Cardiol 2011; 58:2322-8. [DOI: 10.1016/j.jacc.2011.06.073] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 06/08/2011] [Accepted: 06/14/2011] [Indexed: 11/18/2022]
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El Masry H, Breall JA. Alcohol septal ablation for hypertrophic obstructive cardiomyopathy. Curr Cardiol Rev 2011; 4:193-7. [PMID: 19936195 PMCID: PMC2780820 DOI: 10.2174/157340308785160561] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2008] [Revised: 04/09/2008] [Accepted: 04/09/2008] [Indexed: 11/23/2022] Open
Abstract
Since its original description in 1994, alcohol septal ablation (ASA) has emerged as a minimally invasive modality for treatment of hypertrophic obstructive cardiomyopathy compared to surgical myomectomy. This catheter-based intervention relies on the injection of absolute alcohol into the septal perforator to induce a controlled infarction of the hypertrophied septum and consequently abolish the dynamic outflow obstruction. This gradient reduction has been correlated with a significant clinical improvement in the patient’s symptomatology and with left ventricular remodeling. The procedure has been refined throughout the years, especially with the introduction of myocardial contrast echocardiography for localization of the area at risk of infarction and the reduction in the amount of alcohol used. Major complications of ASA are uncommon in large referral centers but conduction system disturbances has been the most commonly reported complications of ASA with 10% of patients necessitating permanent pacemaker implantation for complete heart block. ASA has not been compared to the gold standard surgical myomectomy in a randomized prospective study. We review the clinical aspects of this procedure and provide some historical background.
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Affiliation(s)
- Hicham El Masry
- Krannert Institute of Cardiology, Indiana University School of Medicine
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46
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Geske JB, Sorajja P, Ommen SR, Nishimura RA. Variability of Left Ventricular Outflow Tract Gradient During Cardiac Catheterization in Patients With Hypertrophic Cardiomyopathy. JACC Cardiovasc Interv 2011; 4:704-9. [DOI: 10.1016/j.jcin.2011.02.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 02/02/2011] [Accepted: 02/18/2011] [Indexed: 11/25/2022]
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Fassa AA, Sigwart U. Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy. Interv Cardiol 2011. [DOI: 10.1002/9781444319446.ch26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Fifer MA, Sigwart U. Controversies in cardiovascular medicine. Hypertrophic obstructive cardiomyopathy: alcohol septal ablation. Eur Heart J 2011; 32:1059-64. [PMID: 21447511 DOI: 10.1093/eurheartj/ehr013] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Alcohol septal ablation (ASA) was introduced in 1994 as an alternative to septal myectomy for patients with hypertrophic obstructive cardiomyopathy and symptoms refractory to medical therapy. This procedure alleviates symptoms by producing a targeted, limited infarction of the upper interventricular septum, resulting in an increase in left ventricular outflow tract (LVOT) diameter, a decrease in LVOT gradient, and regression of the component of LV hypertrophy that is due to pressure overload. Clinical success, with improvement in symptoms and reduction in gradient, is achieved in the great majority of patients with either resting or provocable LVOT obstruction. The principal morbidity of the procedure is complete heart block, resulting in some patients in the requirement for a permanent pacemaker. The introduction of myocardial contrast echocardiography as a component of the ASA procedure has contributed to the induction of smaller myocardial infarctions with lower dosages of alcohol and, in turn, fewer complications. Non-randomized comparisons of septal ablation and septal myectomy have shown similar mortality rates and post-procedure New York Heart Association class for the two procedures.
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Affiliation(s)
- Michael A Fifer
- Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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49
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Jensen MK, Havndrup O, Hassager C, Helqvist S, Kelbæk H, Jørgensen E, Køber L, Bundgaard H. Survival and sudden cardiac death after septal ablation for hypertrophic obstructive cardiomyopathy. SCAND CARDIOVASC J 2011; 45:153-60. [DOI: 10.3109/14017431.2011.565793] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | - Ole Havndrup
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Christian Hassager
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Steffen Helqvist
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Henning Kelbæk
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Erik Jørgensen
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Lars Køber
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Henning Bundgaard
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, Denmark
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Proctor RD, Shambrook JS, McParland P, Peebles CR, Brown IW, Harden SP. Imaging hypertrophic heart diseases with cardiovascular MR. Clin Radiol 2011; 66:176-86. [PMID: 21216334 DOI: 10.1016/j.crad.2010.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 08/21/2010] [Accepted: 09/03/2010] [Indexed: 01/02/2023]
Abstract
The assessment of ventricular hypertrophy is an increasingly common indication for cardiac MR (CMR) in every day clinical practice. CMR is useful to confirm the presence of hypertrophy and to help to define the underlying cause through a combination of a detailed assessment of ventricular function and tissue characterising sequences. As well as being a useful diagnostic tool, some CMR imaging features are of prognostic significance. In this article, we review the typical appearances of common forms of ventricular hypertrophy, focussing principally on left ventricular hypertrophy, and demonstrate the techniques that can be used to differentiate one form of hypertrophy from another.
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Affiliation(s)
- Robin D Proctor
- Department of Cardiothoracic Radiology, Southampton University Hospitals NHS Trust, Southampton, UK
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