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Ta S, Li J, Hsi DH, Hu R, Lei C, Shan B, Li W, Wang J, Wang B, Kang N, Li X, Liu J, Qi C, Huang J, Han Y, Ruan F, Zhang J, Liu L. Percutaneous intramyocardial septal radiofrequency ablation after 5-year follow-up. Heart 2024; 110:792-799. [PMID: 38388470 DOI: 10.1136/heartjnl-2023-323606] [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: 10/17/2023] [Accepted: 01/20/2024] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVE The objective is to evaluate the 5-year follow-up results of percutaneous intramyocardial septal radiofrequency ablation (PIMSRA) for hypertrophic obstructive cardiomyopathy (HOCM), including clinical status, electrocardiographic and echocardiographic characteristics. METHODS 27 patients (age: 44.3±15.5 years; 67% men, 33% women) with severely symptomatic HOCM who underwent PIMSRA from October 2016 to September 2017 were included. Their clinical status, resting and exercise stress echocardiography, electrocardiography and cardiac MRI (CMRI) after long-term follow-up were assessed. RESULTS One patient died of intracerebral haemorrhage 1 year post procedurally. The New York Heart Association class, Canadian Cardiovascular Society class and exercise-induced syncopal attacks improved significantly in 26 patients (all p<0.01). Left ventricular (LV) outflow tract gradients revealed sustained reduction (resting: from 95.0 to 9.0 mm Hg, p<0.001; post exercise: from 130.5 to 21.0 mm Hg, p<0.001). The echocardiographic evaluation revealed decreased septal thickness, LV posterior wall thickness and left atrial (LA) diameter (all p<0.001). CMRI data revealed decrease in LV mass index and LA volume index and increase in LV end-diastolic volume index and stroke volume index between baseline and long-term follow-up (all p<0.05). The global longitudinal strain of LV improved from (-11.9%±3.7%) before the procedure to (-13.1%±3.9%) at the last check (p<0.001). Malignant ventricular arrhythmia and heart failure events were not observed. CONCLUSIONS PIMSRA can effectively alleviate symptoms in patients with HOCM and improve their hemodynamics in the long term. TRIAL REGISTRATION NUMBER NCT02888132.
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Affiliation(s)
- Shengjun Ta
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Jing Li
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - David H Hsi
- Heart & Vascular Institute, Stamford Hospital, CT and Columbia University College of Physicians & Surgeons, New York, New York, USA
| | - Rui Hu
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Changhui Lei
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Bo Shan
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Wenxia Li
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Jing Wang
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Bo Wang
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Nan Kang
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiaojuan Li
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Jiani Liu
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Caixia Qi
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Junzhe Huang
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yupeng Han
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Fangqi Ruan
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Jun Zhang
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Liwen Liu
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
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Veselka J. Looking Back at 30 Years of Alcohol Septal Ablation and Looking Forward to the Future. Can J Cardiol 2024; 40:824-832. [PMID: 37774969 DOI: 10.1016/j.cjca.2023.09.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/31/2023] [Accepted: 09/22/2023] [Indexed: 10/01/2023] Open
Abstract
In the 30 years since Dr Sigwart's first pioneering procedures, alcohol septal ablation (ASA) has become the standard catheterisation procedure to reduce or eliminate obstruction in the left ventricular outflow tract. This procedure reduces the pressure gradient by 70%-80%, and only 10%-20% of patients have a residual gradient > 30 mm Hg after ASA. The mortality rate of the procedure is < 1%, and ∼ 10% of patients require permanent pacemaker implantation for higher degrees of atrioventricular block. Given the potential risks, ASA should be performed only in centres with extensive experience in the treatment of hypertrophic cardiomyopathy and with comprehensive therapeutic options, including myectomy. In the future, ASA is likely to be increasingly complemented by catheter-based mitral valve repair, which will increase its efficacy.
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Bode WD, Bode MF, Zhao M, Palacios I, Sakhuja R, Fifer MA, Mela T. Predictors of cardiovascular implantable electronic device dependence at long-term follow-up after alcohol septal ablation in hypertrophic cardiomyopathy patients. J Interv Card Electrophysiol 2023; 66:2071-2080. [PMID: 37043093 DOI: 10.1007/s10840-023-01532-w] [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: 10/13/2022] [Accepted: 03/15/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND The most common complication of alcohol septal ablation (ASA) is transient periprocedural high-grade AV block (HGAVB). To date, no long-term follow-up of cardiovascular implantable electronic device (CIED) utilization after ASA has been reported. We hypothesized that CIED dependence on long-term follow-up can be predicted by ECG or procedural characteristics. METHODS We analyzed all patients with HCM who underwent ASA from December 1998 to December 2019 and received their first CIED within 30 days after ASA for HGAVB. All follow-up interrogations were reviewed. CIED dependence was defined as ventricular pacing of ≥ 5%. RESULTS A total of 138 patients with HCM underwent ASA. Of these, 35 had a prior device and were excluded. Of the remaining 103 patients, 25 patients received a CIED for HGAVB within 30 days after ASA. Average follow-up duration was 10.1 years. On long-term follow-up, 16 patients (64%) were found to be CIED-dependent. Baseline characteristics, including pre- and post-ASA ECG, were not significantly different between dependent and non-dependent patients. The only predictor for CIED dependence was > 1 ml of alcohol injected (OR 6.0, p = 0.031). CONCLUSIONS CIED implantation after ASA is common. Almost two thirds of patients who received a CIED for post-procedural HGAVB were CIED-dependent on long-term follow-up. CIED dependence can be predicted by the amount of injected alcohol > 1 ml.
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Affiliation(s)
- Weeranun D Bode
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Michael F Bode
- Division of Cardiology, Temple University, Philadelphia, PA, USA
| | - Megan Zhao
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Igor Palacios
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rahul Sakhuja
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael A Fifer
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Hypertrophic Cardiomyopathy Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Theofanie Mela
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Veselka J, Liebregts M, Cooper R, Faber L, Januska J, Tesarkova KH, Hansen PR, Seggewiss H, Hansvenclova E, Bonaventura J, Vejtasova V, Ten Berg J, Stables RH, Jensovsky M. Outcomes of Alcohol Septal Ablation in Patients With Severe Left Ventricular Outflow Tract Obstruction: A Propensity Score Matching Analysis. Can J Cardiol 2023; 39:1622-1629. [PMID: 37355228 DOI: 10.1016/j.cjca.2023.06.417] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND The current ACC/AHA guidelines on hypertrophic cardiomyopathy (HCM) caution that alcohol septal ablation (ASA) might be less effective in patients with left ventricular outflow tract obstruction (LVOTO) ≥ 100 mm Hg. METHODS We used a multinational registry to evaluate the outcome of ASA patients according to baseline LVOTO. RESULTS A total of 1346 ASA patients were enrolled and followed for 5.8 ± 4.7 years (7764 patient-years). The patients with baseline LVOTO ≥ 100 mm Hg were significantly older (61 ± 14 years vs 57 ± 13 years; P < 0.01), more often women (60% vs 45%; P < 0.01), and had a more pronounced HCM phenotype than those with baseline LVOTO < 100 mm Hg. There were no significant differences in the occurrences of 30-day major cardiovascular adverse events in the 2 groups. After propensity score matching (2 groups, 257 pairs of patients), the long-term survival was similar in both groups (P = 0.10), the relative reduction of LVOTO was higher in the group with baseline LVOTO ≥ 100 mm Hg (82 ± 21% vs 73 ± 26%; P < 0.01), but the residual resting LVOTO remained higher in this group (23 ± 29 mm Hg vs 13 ± 13 mm Hg; P < 0.01). Dyspnoea (NYHA functional class) at the most recent clinical check-up was similar in the 2 groups (1.7 ± 0.7 vs 1.7 ± 0.7; P = 0.85), and patients with baseline LVOTO ≥ 100 mm Hg underwent more reinterventions (P = 0.02). CONCLUSIONS After propensity matching, ASA patients with baseline LVOTO ≥ 100 mm Hg had similar survival and dyspnoea as patients with baseline LVOTO < 100 mm Hg, but their residual LVOTO and risk of repeated procedures were higher.
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Affiliation(s)
- Josef Veselka
- Department of Cardiology, Second Medical School, Charles University, University Hospital Motol, Prague, Czech Republic.
| | - Max Liebregts
- Department of Cardiology, St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Robert Cooper
- Department of Sports and Exercise Medicine, John Moores University, Liverpool, England, United Kingdom; Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Liverpool, England, United Kingdom
| | | | | | - Klara Hulikova Tesarkova
- Department of Demography and Geodemography, Faculty of Science, Charles University, Prague, Czech Republic
| | - Peter Riis Hansen
- Department of Cardiology, Herlev and Gentofte Hospital, Hellerup, Denmark
| | - Hubert Seggewiss
- Comprehensive Heart Failure Centre, University Clinic Wuerzburg, Wuerzburg, Germany
| | - Eva Hansvenclova
- Department of Cardiology, Second Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Jiri Bonaventura
- Department of Cardiology, Second Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Veronika Vejtasova
- Department of Cardiology, Second Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Jurriën Ten Berg
- Department of Cardiology, St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Rodney Hilton Stables
- Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Liverpool, England, United Kingdom
| | - Michael Jensovsky
- Department of Cardiology, Second Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
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A novel risk model to predict all-cause mortality in patients undergoing percutaneous transluminal septal myocardial ablation for hypertrophic obstructive cardiomyopathy. CARDIOLOGY PLUS 2022. [DOI: 10.1097/cp9.0000000000000031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Al Lawati H, Nadar SK, Al Riyami AB. Percutaneous Septal Reduction Therapy in a Patient with Severely Symptomatic Hypertrophic Obstructive Cardiomyopathy: An experience from a tertiary care centre. Sultan Qaboos Univ Med J 2022; 22:443-447. [PMID: 36407690 PMCID: PMC9645511 DOI: 10.18295/squmj.3.2022.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/04/2022] [Accepted: 03/06/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Hatim Al Lawati
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | - Sunil K. Nadar
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | - Adil B. Al Riyami
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
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Chen Y, Zhao X, Yuan J, Zhang Y, Liu W, Qiao S. Preoperative myocardial fibrosis is associated with worse survival after alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy: A delayed enhanced cardiac magnetic resonance study. Front Cardiovasc Med 2022; 9:924804. [PMID: 36035960 PMCID: PMC9403173 DOI: 10.3389/fcvm.2022.924804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/20/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPrior studies have shown that myocardial fibrosis can be detected by late gadolinium enhancement (LGE) of cardiac magnetic resonance (CMR) and might be associated with higher mortality risk in hypertrophic cardiomyopathy (HCM). The objective of this study was to examine the prognostic utility of CMR in patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing alcohol septal ablation (ASA).Materials and methodsWe conducted a retrospective study which consisted of 183 consecutive patients with symptomatic drug-refractory HOCM who underwent CMR for assessment of myocardial fibrosis before ASA. The cardiovascular disease related survival was evaluated according to LGE-CMR status.ResultsThe cohort comprised 74 (40.4%) women with a mean age of 51 ± 8 years. Preoperative myocardial fibrosis was detected in 148 (80.9%) patients. After a median of 6 years (range 2–11 years) follow-up, adverse clinical events occurred in 14 (7.7%) patients. Multivariate-adjusted Cox regression analyses revealed that age [hazard ratio (HR) 1.142 (1.059–1.230), p = 0.001] and LGE [HR 1.170 (1.074–1.275), p < 0.001] were independent predictors of cardiovascular mortality during follow-up.ConclusionPreoperative myocardial fibrosis measured by LGE-CMR was an independent predictor of increased adverse clinical outcomes in patients with HOCM undergoing ASA and could be used for the pre-operative evaluation of risk stratification and long-term prognosis after ASA in these patients.
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Affiliation(s)
- Youzhou Chen
- Department of Cardiology, Beijing Jishuitan Hospital, Beijing, China
- *Correspondence: Youzhou Chen,
| | - Xingshan Zhao
- Department of Cardiology, Beijing Jishuitan Hospital, Beijing, China
| | - Jiansong Yuan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Zhang
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Liu
- Department of Cardiology, Beijing Jishuitan Hospital, Beijing, China
- Wei Liu,
| | - Shubin Qiao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Shubin Qiao,
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Meng X, Wang WY, Gao J, Zhang K, Zheng J, Wang JJ, Liu Y, Shao C, Tang YD. Hypertrophic Obstructive Cardiomyopathy: Comparison of Outcomes After Myectomy or Alcohol Ablation. Front Cardiovasc Med 2022; 9:755376. [PMID: 35360040 PMCID: PMC8964041 DOI: 10.3389/fcvm.2022.755376] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 01/21/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction and Objectives The risk of ventricular arrhythmia and heart failure in patients with hypertrophic obstructive cardiomyopathy (HOCM) is much higher than that in the general population. More and more pieces of evidence showed that HOCM is the leading cause of sudden cardiac death in young people. We reported our experience in a study, comparing surgical myectomy, alcohol septal ablation (ASA), and medical therapy. Methods The original cohort included 965 consecutive patients with HOCM. The patients were divided into three groups according to treatment strategies: myectomy group (n = 502), ASA group (n = 138), and medical treatment group (n = 325). The median follow-up duration was 42.99 ± 18.32 months, and the primary endpoints were all-cause mortality and heart transplantation. Results Both in short- and long-term observations, surgical myectomy reduced the left ventricular outflow tract (LVOT) gradients more effectively (7 days, 16.15 ± 12.07 mmHg vs. 42.33 ± 27.76 mmHg, p < 0.05; 1 year, 14.65 ± 13.18 mmHg vs. 41.17 ± 30.76 mmHg, p < 0.05). Among the three groups, the patients in the medical treatment group were at a higher risk of mortality and cardiac transplantation (vs. the myectomy group, p < 0.001 by log-rank test; vs. the alcohol septal ablation group, p = 0.017 by log-rank test), and the myectomy group shows a lower risk of reaching the primary endpoint than the two other groups. In the multivariate Cox regression analysis, previous atrial fibrillation (AF), N terminal pro B type natriuretic peptide (NT-pro-BNP), and surgical myectomy predicted an HOCM prognosis. However, the impact of surgical myectomy on HOCM prognosis seems to be limited to the <56 years group. Conclusions The patients with medical treatments seemed to suffer from the highest risk of achieving an all-cause mortality and the endpoint of heart transplantation. In the long-term survival and clinical outcome, myectomy seemed better than alcohol septal ablation, especially the younger patients. Due to the less-controllable degree, periprocedural complication frequency after alcohol septal ablation was higher, compared with myectomy. Furthermore, gradients after myectomy are lower at late follow-up. To sum up, when selecting treatment strategies, the patients should be individually evaluated by a multidisciplinary team of cardiologists and surgeons.
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Affiliation(s)
- Xiangbin Meng
- Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Wen-Yao Wang
- Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Jun Gao
- Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Kuo Zhang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jilin Zheng
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing-Jia Wang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - YuPeng Liu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chunli Shao
- Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Yi-Da Tang
- Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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La Canna G, Scarfò I, Arendar I, Colombo A, Torracca L, Margonato D, Montorfano M, Alfieri O. Targeting Alcohol Septal Ablation in Patients with Obstructive Hypertrophic Cardiomyopathy Candidates for Surgical Myectomy: Added Value of Three-Dimensional Intracoronary Myocardial Contrast Echocardiography. J Clin Med 2021; 10:jcm10102166. [PMID: 34067830 PMCID: PMC8156226 DOI: 10.3390/jcm10102166] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/11/2021] [Accepted: 05/14/2021] [Indexed: 01/06/2023] Open
Abstract
Background: Myocardial contrast two-dimensional echocardiography (MC-2DE) is widely used to address alcohol septal ablation (ASA) in obstructive hypertrophic cardiomyopathy (HCM). Owing to its limited cut-planes, MC-2DE may inaccurately identify the contrast misplacement associated with an unsuccessful or complicated ASA outcome. Objective: The aim of this study was to assess the added value of myocardial contrast three-dimensional echocardiography (MC-3DE) compared with MC-2DE to identify the appropriate matching between the target septal zone (TSZ) and coronary artery branch for safe and long-term effective ASA in HCM patients. Methods: A consecutive series of 52 symptomatic obstructive HCM patients referred for isolated surgical myectomy (SM) was analyzed with MC-2DE and MC-3DE following injection of echocontrast into one or more septal branches. MC-2DE and MC-3DE patterns were categorized according to complete (Type 1) or incomplete (Type 2) TSZ covering, high-risk (Type 3) exceeding TSZ, or life-threatening outside TSZ distribution (Type 4). Results: MC-2DE per patient analysis showed a Type 1 pattern in 32 patients and Types 2–4 in the remaining 20 patients; subsequent MC-3DE analysis provided a re-phenotyping of MC-2DE findings in 22 of the 52 patients (42%), showing a high-risk Type 2 pattern in 17 of the 32 patients with Type 1, and a new life-threatening Type 4 in three patients with Type 2, respectively. All patients with MC-3DE Type 1 pattern underwent safe and effective ASA with a long-term uneventful follow-up, while the remaining patients underwent SM. Conclusions: Refining high risk or life-threatening contrast misplacement, MC-3DE is more accurate than conventional MC-2DE to target safe and long-term effective septal reduction with ASA in obstructive HCM patients referred for isolated SM.
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Affiliation(s)
- Giovanni La Canna
- Applied Diagnostic Echocardiography Unit, IRCCS Humanitas Clinical and Research Center, 20089 Rozzano, Italy; (I.S.); (I.A.)
- Correspondence: ; Tel.: +39-33-5674-4319
| | - Iside Scarfò
- Applied Diagnostic Echocardiography Unit, IRCCS Humanitas Clinical and Research Center, 20089 Rozzano, Italy; (I.S.); (I.A.)
| | - Irina Arendar
- Applied Diagnostic Echocardiography Unit, IRCCS Humanitas Clinical and Research Center, 20089 Rozzano, Italy; (I.S.); (I.A.)
| | - Antonio Colombo
- Interventional Cardiology Unit, IRCCS Humanitas Clinical and Research Center, 20089 Rozzano, Italy;
| | - Lucia Torracca
- Cardiac Surgery, IRCCS Humanitas Clinical and Research Center, 20089 Rozzano, Italy;
| | - Davide Margonato
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (D.M.); (M.M.)
| | - Matteo Montorfano
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (D.M.); (M.M.)
| | - Ottavio Alfieri
- Cardiac Surgery Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy;
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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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Alcohol Septal Ablation versus Septal Myectomy Treatment of Obstructive Hypertrophic Cardiomyopathy: A Systematic Review and Meta-Analysis. J Clin Med 2020; 9:jcm9103062. [PMID: 32977442 PMCID: PMC7598206 DOI: 10.3390/jcm9103062] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022] Open
Abstract
Surgical myectomy (SM) and alcohol septal ablation (ASA) are two invasive therapies for symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM), despite medical therapy. This meta-analysis aims to compare the efficacy of the two procedures. We searched all electronic databases until February 2020 for clinical trials and cohorts comparing clinical outcomes of ASA and SM treatment of patients with HOCM. The primary endpoint was all-cause mortality, cardiovascular (CV) mortality, sudden cardiac death (SCD), re-intervention, and complications. Secondary endpoints included relief of clinical symptoms and drop of left ventricular outflow tract (LVOT) gradient. Twenty studies (4547 patients; 2 CTs and 18 cohorts) comparing ASA vs. SM with a mean follow-up of 47 ± 28.7 months were included. Long term (8.72 vs. 7.84%, p = 0.42) and short term (1.12 vs. 1.27%, p = 0.93) all-cause mortality, CV mortality (2.48 vs. 3.66%, p = 0.26), SCD (1.78 vs. 0.76%, p = 0.20) and stroke (0.36 vs. 1.01%, p = 0.64) were not different between procedures. ASA was associated with lower peri-procedural complications (5.57 vs. 10.5%, p = 0.04) but higher rate of re-interventions (10.1 vs. 0.27%; p < 0.001) and pacemaker dependency (12.4 vs. 4.31%, p = 0.0004) compared to SM. ASA resulted in less reduction in LVOT gradient (-47.8 vs. -58.4 mmHg, p = 0.01) and less improvement of clinical symptoms compared to SM (New York Heart Association (NYHA) class III/IV, 82.4 vs. 94.5%, p < 0.001, angina 53.2 vs. 84.2%, p = 0.02). Thus, ASA and SM treatment of HOCM carry a similar risk of mortality. Peri-procedural complications are less in alcohol ablation but re-intervention and pacemaker implantations are more common. These results might impact the procedure choice in individual patients, for the best clinical outcome.
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Lam MC, Naidu SS, Kolte D, Kennedy K, Feldman DN, Chu AF, Abbott JD, Gordon P, Aronow HD. Cardiac implantable electronic device placement following alcohol septal ablation for hypertrophic cardiomyopathy in the United States. J Cardiovasc Electrophysiol 2020; 31:2712-2719. [PMID: 32671899 DOI: 10.1111/jce.14679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/27/2020] [Accepted: 07/04/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cardiac implantable electronic devices (CIED) are sometimes required after alcohol septal ablation (ASA) for hypertrophic cardiomyopathy (HCM). The primary objectives of this study were to characterize the incidence, timing, and predictors of CIED placement after ASA for HCM. METHODS Patients were identified from the 2010-2015 Nationwide Readmissions Databases. Incidence, timing and independent predictors of CIED placement, as well as 30-day readmission rates were examined. RESULTS There were 1296 patients (national estimate = 2864) with HCM who underwent ASA. CIED were implanted in 322 (25% overall; 14% permanent pacemaker, 11% implantable cardioverter defibrillator) during the index hospitalization. Of these, 21%, 23%, 21%, and 18% occurred on postprocedure day 0, 1, 2, and 3, respectively. Only 17 (1.3%) patients underwent CIED implantation between discharge and 30-day follow up. Independent predictors of index hospitalization CIED implantation included older age, diabetes, heart failure, nonelective index hospital admission and hospitalization at a privately owned hospital. Nonelective 30-day readmission rates among those who did and did not undergo CIED placement during their index hospitalization, were 6.8% and 7.9%, respectively (p = .53); median time to readmission was also similar between groups. CONCLUSIONS One in four HCM patients undergoing ASA underwent CIED implantation during their index hospitalization; nearly 2/3rd during the first 48 h postprocedure. Private hospital ownership independently predicted CIED placement. More data are needed to better understand the unexpectedly high rates of CIED placement, earlier than anticipated timing of implantation and differential rates by hospital ownership.
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Affiliation(s)
- Matthew C Lam
- Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Srihari S Naidu
- Division of Cardiology, Westchester Medical Center, New York Medical College, Westchester, New York
| | - Dhaval Kolte
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Dmitriy N Feldman
- Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Antony F Chu
- Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Division of Cardiology, Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - J Dawn Abbott
- Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Division of Cardiology, Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Paul Gordon
- Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Division of Cardiology, Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Herbert D Aronow
- Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Division of Cardiology, Lifespan Cardiovascular Institute, Providence, Rhode Island
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Recommendations of the current guidelines for implantable cardioverter-defibrillator implantation in patients with hypertrophic cardiomyopathy: Debate still exists. J Interv Card Electrophysiol 2020; 60:1-7. [DOI: 10.1007/s10840-020-00837-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/21/2020] [Indexed: 10/23/2022]
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Makavos G, Κairis C, Tselegkidi ME, Karamitsos T, Rigopoulos AG, Noutsias M, Ikonomidis I. Hypertrophic cardiomyopathy: an updated review on diagnosis, prognosis, and treatment. Heart Fail Rev 2020; 24:439-459. [PMID: 30852773 DOI: 10.1007/s10741-019-09775-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hypertrophic cardiomyopathy (HCM) represents a phenotype of left ventricular hypertrophy unexplained by abnormal loading conditions. The definition is based on clinical criteria; however, there are numerous underlying etiologic factors. The MOGE(S) classification provides a standardized approach for multimodal characterization of HCM. HCM is associated with increased morbidity and mortality, and especially the assessment of the risk of sudden cardiac death is of paramount importance. In this review, we summarize essential knowledge and recently published data on clinical presentation, diagnosis, genetic analyses, differential diagnosis, prognosis, and treatment options that are necessary for understanding and management of HCM.
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Affiliation(s)
- George Makavos
- 2nd Cardiology Department, National and Kapodistrian University of Athens, Attikon Hospital, Rimini 1, 12462, Haidari, Greece
| | - Chris Κairis
- 2nd Cardiology Department, National and Kapodistrian University of Athens, Attikon Hospital, Rimini 1, 12462, Haidari, Greece
| | - Maria-Eirini Tselegkidi
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, "Alexandra" Hospital, Vassilisis Sofias Avenue 80, 11528, Athens, Greece
| | - Theodoros Karamitsos
- 1st Department of Cardiology, Aristotle University of Thessaloniki, AHEPA Hospital, Kiriakidi 1, 54621, Thessaloniki, Greece
| | - Angelos G Rigopoulos
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany
| | - Michel Noutsias
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany
| | - Ignatios Ikonomidis
- 2nd Cardiology Department, National and Kapodistrian University of Athens, Attikon Hospital, Rimini 1, 12462, Haidari, Greece.
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Rigopoulos AG, Panou F, Sakadakis E, Frogoudaki A, Papadopoulou K, Triantafyllidi H, Ali M, Iliodromitis E, Rizos I, Noutsias M. Cardiopulmonary Exercise Test Parameters at Three Months After Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy Are Associated With Late Clinical Outcome. Heart Lung Circ 2020; 29:202-210. [DOI: 10.1016/j.hlc.2018.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/27/2018] [Accepted: 12/15/2018] [Indexed: 11/27/2022]
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Risk stratification in hypertrophic cardiomyopathy. Herz 2020; 45:50-64. [PMID: 29696341 DOI: 10.1007/s00059-018-4700-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/15/2018] [Accepted: 03/24/2018] [Indexed: 12/20/2022]
Abstract
Sudden cardiac death (SCD) is the most devastating complication of hypertrophic cardiomyopathy (HCM). The greatest challenge in the management of HCM is identifying those at increased risk, since an implantable cardioverter-defibrillator (ICD) is a potentially life-saving therapy. We sought to summarize the available data on SCD in HCM and provide a clinical perspective on the current differing and somewhat conflicting data on risk stratification, with balanced guidance regarding rational clinical decision-making. Additionally, we sought to determine the status of the current implementation of guidelines compiled by HCM experts worldwide. The HCM Risk-SCD model helps improve the risk stratification of HCM patients for primary prevention of SCD by calculating an individual risk estimate that contributes to the clinical decision-making process. Improved risk stratification is important for decision-making before ICD implantation for the primary prevention of SCD.
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El-Sabawi B, Nishimura RA, Barsness GW, Cha YM, Geske JB, Eleid MF. Temporal Occurrence of Arrhythmic Complications After Alcohol Septal Ablation. Circ Cardiovasc Interv 2020; 13:e008540. [PMID: 31973555 DOI: 10.1161/circinterventions.119.008540] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The temporal occurrence of arrhythmic complications after alcohol septal ablation (ASA) is unclear. As a result, the appropriate time to monitor patients after ASA is controversial. The purpose of this study is to determine the temporal occurrence of complete heart block (CHB) and ventricular tachyarrhythmia (VT) after ASA to better understand when patients can be safely discharged. METHODS Consecutive patients treated with ASA for hypertrophic cardiomyopathy from 2003 to 2019 at a tertiary referral center were reviewed retrospectively. The incidence and timing of CHB or sustained VT within 30 days post-ASA were assessed. RESULTS A total of 243 patients were included in this study. Mean maximal septal thickness was 19.0±3.9 mm, and total volume of ethanol injected was 1.7±0.6 mL. CHB occurred in 59 (24.3%) patients, including transient CHB in 33 (13.6%) and permanent in 26 (10.7%). The initial episode of CHB occurred within 24 hours post-ASA in 51 (21.0%) patients, between 24 and 48 hours in 3 (1.2%), between 48 and 72 hours in 3 (1.2%), and after 72 hours in 2 (0.8%). New permanent pacemaker was placed in 46 (18.3%). Presence of baseline bundle branch block and age ≥70 were significantly associated with CHB but not CHB presenting after 24 hours. VT occurred in 3 (1.2%) patients, including 1 (0.4%) within 24 hours, 1 (0.4%) between 24 and 48 hours, and 1 (0.4%) after 72 hours. VT required cardioversion in 2 patients and new implantable cardioverter-defibrillator placement in 2. CONCLUSIONS The incidence of CHB or VT presenting after 72 hours post-ASA was low. These findings suggest that timely discharge of patients without evidence of early conduction disturbances after ASA can be considered as a potentially safe management strategy, especially in patients without preexisting conduction abnormalities.
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Affiliation(s)
| | - Rick A Nishimura
- Department of Cardiovascular Diseases (R.A.N., G.W.B., Y.-M.C., J.B.G., M.F.E.), Mayo Clinic, Rochester, MN
| | - Gregory W Barsness
- Department of Cardiovascular Diseases (R.A.N., G.W.B., Y.-M.C., J.B.G., M.F.E.), Mayo Clinic, Rochester, MN
| | - Yong-Mei Cha
- Department of Cardiovascular Diseases (R.A.N., G.W.B., Y.-M.C., J.B.G., M.F.E.), Mayo Clinic, Rochester, MN
| | - Jeffrey B Geske
- Department of Cardiovascular Diseases (R.A.N., G.W.B., Y.-M.C., J.B.G., M.F.E.), Mayo Clinic, Rochester, MN
| | - Mackram F Eleid
- Department of Cardiovascular Diseases (R.A.N., G.W.B., Y.-M.C., J.B.G., M.F.E.), Mayo Clinic, Rochester, MN
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Rigopoulos AG, Sakellaropoulos S, Ali M, Mavrogeni S, Manginas A, Pauschinger M, Noutsias M. Transcatheter septal ablation in hypertrophic obstructive cardiomyopathy: a technical guide and review of published results. Heart Fail Rev 2019; 23:907-917. [PMID: 29736811 DOI: 10.1007/s10741-018-9706-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Transcatheter alcohol septal ablation (ASA) treatment of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) is based on the existence and degree of intraventricular obstruction. Patients with significant gradient and symptoms who do not respond to optimal medical therapy are eligible to gradient reduction through a surgical (septal myectomy) or a transcatheter (alcohol septal ablation) septal reduction. The latter encompasses occlusion of a septal branch perfusing the hypertrophied septum, which is involved in the generation of obstruction, by injecting ethanol into the supplying septal branch(es). ASA has been established as a highly effective and safe method and has outnumbered the surgical gold standard. Although the technique is straightforward, patient selection and some technical details may influence the efficacy and safety of the procedure. The technique is based on echocardiographic contrast guidance, which allows accurate target septal branch selection and optimisation of the result. Published long-term results from high-volume centres have confirmed the effectiveness of ASA and have shown excellent survival, which is comparable to that in the general population. Choice and performance of the surgical or interventional treatment should be implemented in highly specialised centres in terms of a heart-team approach, taking notice of anatomic characteristics as well as comorbidities. Involvement of all cases in international registries may reveal the individual merits and indications for the surgical and interventional treatment in HOCM.
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Affiliation(s)
- Angelos G Rigopoulos
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle, Germany.
| | - Stefanos Sakellaropoulos
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle, Germany
| | - Muhammad Ali
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle, Germany
| | - Sophie Mavrogeni
- Onassis Cardiac Surgery Center, 50 Esperou Street, 175-61, Palaeo Faliro, Athens, Greece
| | - Athanassios Manginas
- Interventional Cardiology and Cardiology Department, Mediterraneo Hospital, Ilias Street 8-12, 16675, Glyfada, Greece
| | - Matthias Pauschinger
- Department of Cardiology, Internal Medicine 8, Paracelsus Medical University, Nuremberg General Hospital, Nuremberg, Germany
| | - Michel Noutsias
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle, Germany
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Kimmelstiel C, Zisa DC, Kuttab JS, Wells S, Udelson JE, Wessler BS, Rastegar H, Kapur NK, Weintraub AR, Maron BJ, Maron MS, Rowin EJ. Guideline-Based Referral for Septal Reduction Therapy in Obstructive Hypertrophic Cardiomyopathy Is Associated With Excellent Clinical Outcomes. Circ Cardiovasc Interv 2019; 12:e007673. [PMID: 31296080 DOI: 10.1161/circinterventions.118.007673] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The outcome of medically refractory patients with obstructive hypertrophic cardiomyopathy treated according to the American College of Cardiology/American Heart Association consensus guideline recommendations is not known. The objectives of this study were to define the short- and long-term outcomes of medically refractory obstructive hypertrophic cardiomyopathy patients undergoing alcohol septal ablation (ASA) and surgical septal myectomy (SM) with patient management in accordance with these consensus guidelines, as well as to quantify procedural risk and burden of comorbid conditions at the time of treatment. METHODS AND RESULTS Patients with obstructive hypertrophic cardiomyopathy referred for either ASA or SM from 2004 to 2015 were followed for the primary end point of short- and long-term mortality and compared with respective age- and sex-matched US populations. Of 477 consecutive severely symptomatic patients, 99 underwent ASA and 378 SM. Compared with SM, ASA patients were older ( P<0.001), had a higher burden of comorbid conditions ( P<0.01), and significantly higher predicted surgical mortality ( P<0.005). Procedure-related mortality was 0.3% and similarly low in both groups (0% in ASA and 0.8% in SM). Over 4.0±2.9 years of follow-up, 95% of patients had substantial improvement in heart failure symptoms to New York Heart Association class I/II (96% in SM and 90% in ASA). Long-term mortality was similar between the 2 groups with no difference compared with age- and sex-matched US populations. CONCLUSIONS Guideline-based referral for ASA and SM leads to excellent outcomes with low procedural mortality, excellent long-term survival, and improvement in symptoms. These outcomes occur in ASA patients despite being an older cohort with significantly more comorbidities.
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Affiliation(s)
- Carey Kimmelstiel
- Division of Cardiology (C.K., D.C.Z., J.S.K., S.W., J.E.U., B.S.W., N.K.K., A.R.W., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA.,Hypertrophic Cardiomyopathy Center (C.K., H.R., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA
| | - David C Zisa
- Division of Cardiology (C.K., D.C.Z., J.S.K., S.W., J.E.U., B.S.W., N.K.K., A.R.W., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA
| | - Johny S Kuttab
- Division of Cardiology (C.K., D.C.Z., J.S.K., S.W., J.E.U., B.S.W., N.K.K., A.R.W., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA
| | - Sophie Wells
- Division of Cardiology (C.K., D.C.Z., J.S.K., S.W., J.E.U., B.S.W., N.K.K., A.R.W., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA
| | - James E Udelson
- Division of Cardiology (C.K., D.C.Z., J.S.K., S.W., J.E.U., B.S.W., N.K.K., A.R.W., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA
| | - Benjamin S Wessler
- Division of Cardiology (C.K., D.C.Z., J.S.K., S.W., J.E.U., B.S.W., N.K.K., A.R.W., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA
| | - Hassan Rastegar
- Hypertrophic Cardiomyopathy Center (C.K., H.R., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA.,Division of Cardiothoracic Surgery (H.R.), Tufts Medical Center, Boston, MA
| | - Navin K Kapur
- Division of Cardiology (C.K., D.C.Z., J.S.K., S.W., J.E.U., B.S.W., N.K.K., A.R.W., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA
| | - Andrew R Weintraub
- Division of Cardiology (C.K., D.C.Z., J.S.K., S.W., J.E.U., B.S.W., N.K.K., A.R.W., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA
| | - Barry J Maron
- Division of Cardiology (C.K., D.C.Z., J.S.K., S.W., J.E.U., B.S.W., N.K.K., A.R.W., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA.,Hypertrophic Cardiomyopathy Center (C.K., H.R., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA
| | - Martin S Maron
- Division of Cardiology (C.K., D.C.Z., J.S.K., S.W., J.E.U., B.S.W., N.K.K., A.R.W., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA.,Hypertrophic Cardiomyopathy Center (C.K., H.R., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA
| | - Ethan J Rowin
- Division of Cardiology (C.K., D.C.Z., J.S.K., S.W., J.E.U., B.S.W., N.K.K., A.R.W., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA.,Hypertrophic Cardiomyopathy Center (C.K., H.R., B.J.M., M.S.M., E.J.R.), Tufts Medical Center, Boston, MA
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Hoedemakers S, Vandenberk B, Liebregts M, Bringmans T, Vriesendorp P, Willems R, Van Cleemput J. Long-term outcome of conservative and invasive treatment in patients with hypertrophic obstructive cardiomyopathy. Acta Cardiol 2019; 74:253-261. [PMID: 30451084 DOI: 10.1080/00015385.2018.1491673] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background and objective: Treatment for patients with hypertrophic obstructive cardiomyopathy (HOCM) can be either conservative or invasive (alcohol septal ablation (ASA) and myectomy). As there is no clear consensus on the long-term effects of these different strategies, the aim was to compare the long-term outcome in a large tertiary referral university hospital. Methods: We retrospectively included 106 HOCM patients. Twenty-nine (27.4%) patients were treated conservatively, 25 (23.6%) underwent ASA and 52 (49.0%) myectomy. Endpoints were all-cause mortality and sudden cardiac death (SCD)-related events (including SCD, aborted SCD and appropriate ICD shocks). Kaplan-Meier survival analysis and Cox proportional hazard regression models were used. Results: The mean follow-up period was 7.7 ± 4.9 years. Overall, there was no significant difference in survival between the three treatment strategies (p = 0.7). Annual rates of SCD-related events at 5 years and the complete follow-up period were significantly higher (p = 0.034) after conservative treatment (4.9%/year and 2.7%/year, respectively) compared to ASA (0.9%/year, 0.5%/year) and myectomy (1.0%/year, 0.6%/year). Independent predictors of SCD-related events were: conservative treatment (HR 10.66; 1.88-60.55), a known mutation (HR 9.36; 1.43-61.20), left ventricular wall thickness (LVWT) > 30 mm (HR 6.48; 1.05-39.92) and non-sustained VT (HR 16.82; 2.29-123.29). Invasive treatment resulted in a significant higher proportion of patients requiring pacing (p = 0.033). Conclusions: Long-term mortality rates for patients with HOCM are similarly low between treatment groups. However, conservative treatment was associated with SCD-related events, as were known mutations, increased LVWT and non-sustained VT. Invasive treatment was associated with a higher need for implantation of a pacemaker.
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Affiliation(s)
- Sarah Hoedemakers
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Bert Vandenberk
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Max Liebregts
- Department of Cardiology, St. Antonius Ziekenhuis Nieuwegein, Nieuwegein, The Netherlands
| | - Tijs Bringmans
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Rik Willems
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Johan Van Cleemput
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
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Jahnlová D, Tomašov P, Adlová R, Januška J, Krejčí J, Dabrowski M, Veselka J. Outcome of patients ≥ 60 years of age after alcohol septal ablation for hypertrophic obstructive cardiomyopathy. Arch Med Sci 2019; 15:650-655. [PMID: 31110530 PMCID: PMC6524201 DOI: 10.5114/aoms.2019.84735] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 05/29/2017] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION The outcome of patients ≥ 60 years of age after alcohol septal ablation (ASA) for obstructive hypertrophic cardiomyopathy (HCM) remains unresolved. We sought to determine the long-term survival and the causes of death in this population. MATERIAL AND METHODS We enrolled 156 consecutive patients (69 ±6 years, 69% women, follow-up: 4.8 ±3.5 years) who underwent ASA at ≥ 60 years of age. RESULTS The 30-day mortality rate was 1.3%. At the last check-up, 81% of patients were in New York Heart Association class ≤ 2 and 76% had a left ventricular outflow tract gradient (LVOG) ≤ 30 mm Hg. A total of 39 patients died (51% of cardiovascular causes, 44% of non-cardiovascular causes, 5% of unknown causes) during the 734 patient-years. The annual sudden mortality, the sudden mortality and the all-cause mortality rates were 0.5%, 1.1%, and 4.8%, respectively. The all-cause mortality was higher compared to the age- and sex-matched general population (p = 0.002). CONCLUSIONS Alcohol septal ablation was safe and effective in the long-term follow-up. We observed a reduced life expectancy compared to the age- and sex-matched general population. Mortality was almost equally due to cardiovascular and non-cardiovascular causes of death.
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Affiliation(s)
- Denisa Jahnlová
- Department of Cardiology, Charles University in Prague, 2 Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Pavol Tomašov
- Department of Cardiology, Charles University in Prague, 2 Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Radka Adlová
- Department of Cardiology, Charles University in Prague, 2 Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Jaroslav Januška
- Department of Cardiology, Heart Centre, Hospital Podlesí a. s., Třinec, Czech Republic
| | - Jan Krejčí
- St. Anne’s University Hospital, Brno, Czech Republic
| | | | - Josef Veselka
- Department of Cardiology, Charles University in Prague, 2 Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
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Yanagiuchi T, Tada N, Haga Y, Suzuki S, Sakurai M, Taguri M, Ootomo T. Utility of preprocedural multidetector computed tomography in alcohol septal ablation for hypertrophic obstructive cardiomyopathy. Cardiovasc Interv Ther 2019; 34:364-372. [PMID: 30725361 DOI: 10.1007/s12928-019-00574-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 01/23/2019] [Indexed: 10/27/2022]
Abstract
Preprocedural computed tomography (CT) imaging appears to provide an advantage in localization of the appropriate septal branch targeted for alcohol septal ablation (ASA). The objective of this study was to compare the clinical backgrounds, procedural characteristics, and outcomes of patients who underwent ASA with preprocedural CT assessment against those without CT assessment. Thirty consecutive patients with obstructive hypertrophic cardiomyopathy who underwent ASA were retrospectively included. Patients who underwent preprocedural CT (CT-guided ASA group, n = 11) were compared with patients who underwent ASA without CT (traditional ASA group, n = 19). The CT-guided ASA group had a significantly lower number of approached target vessels (1 [interquartile range {IQR}, 1-2] vs. 2 [IQR, 2-3], P = 0.036) and non-ablated target vessels (0 [IQR, 0-1] vs. 1 [IQR, 0-2], P = 0.031) than the traditional ASA group. There were no differences between the two groups in total fluoroscopy time, the amount of delivered radiation dose, and the volume of contrast medium used during the procedures. There were also no differences between the two groups in procedural success rate and improvement of left ventricular outflow tract gradient and New York Heart Association functional class at 1 month follow-up. CT had a significant impact on the ASA procedure diminishing the number of target vessels, and could be a reliable assessment modality to build its procedural strategy.
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Affiliation(s)
- Takashi Yanagiuchi
- Department of Cardiology, Rakuwakai Otowa Hospital, Otowachinji-cho, Yamashina-ku, Kyoto, 607-8062, Japan.,Department of Cardiology, Sendai Kousei Hospital, Hirosemachi, Aoba-ku, Sendai, 980-0873, Japan
| | - Norio Tada
- Department of Cardiology, Sendai Kousei Hospital, Hirosemachi, Aoba-ku, Sendai, 980-0873, Japan.
| | - Yoshihiro Haga
- Department of Radiology, Sendai Kousei Hospital, Hirosemachi, Aoba-ku, Sendai, 980-0873, Japan
| | - Shinichi Suzuki
- Department of Radiology, Sendai Kousei Hospital, Hirosemachi, Aoba-ku, Sendai, 980-0873, Japan
| | - Mie Sakurai
- Department of Cardiology, Sendai Kousei Hospital, Hirosemachi, Aoba-ku, Sendai, 980-0873, Japan
| | - Masataka Taguri
- Department of Biostatistics and Epidemiology, Yokohama City University, Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Tatsushi Ootomo
- Department of Cardiology, Sendai Kousei Hospital, Hirosemachi, Aoba-ku, Sendai, 980-0873, Japan
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Batzner A, Schäfers HJ, V. Borisov K, Seggewiß H. Hypertrophic Obstructive Cardiomyopathy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:47-53. [PMID: 30855006 PMCID: PMC6415619 DOI: 10.3238/arztebl.2019.0047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 08/20/2018] [Accepted: 10/30/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is caused by mutations in a number of genes. Its prevalence is 0.2% to 0.6%. METHODS This review is based on publications retrieved by a selective literature search and on the authors' clinical experi- ence. RESULTS 70% of patients with HCM suffer from the obstructive type of the condition, clinically characterized by highly dynamic and variable manifestations in the form of dyspnea, angina pectoris, and stress-dependent presyncope and syn- cope. Younger patients are at particular risk of sudden cardiac death; thus, all patients need not only symptomatic treatment, but also risk assessment, which can be difficult in individual cases. Left ventricular obstruction, which usually causes symptoms, is treated medically at first, with either a beta- blocker or verapamil. If medical treatment fails, two invasive treatments are available, surgical myectomy and percu- taneous septum ablation. Both of these require a high level of expertise. If performed successfully, they lead to sustained gradient reduction and clinical improvement. Septum ablation is associated with low perioperative and peri-interventional mortality but necessitates permanent pacemaker implantation in 10-20% of patients. CONCLUSION In the absence of evidence from randomized comparison trials, a suitable method of reducing the gradient should be determined by an HCM team in conjunction with each individual patient. Important criteria for decision-making include the anatomical findings and any accompanying illnesses.
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Affiliation(s)
- Angelika Batzner
- Department of Cardiology, Klinikum Würzburg-Mitte, Juliusspital, Würzburg
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Hospital, Homburg/Saar
| | | | - Hubert Seggewiß
- Department of Cardiology, Klinikum Würzburg-Mitte, Juliusspital, Würzburg
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Rigopoulos AG, Ali M, Abate E, Matiakis M, Melnyk H, Mavrogeni S, Leftheriotis D, Bigalke B, Noutsias M. Review on sudden death risk reduction after septal reduction therapies in hypertrophic obstructive cardiomyopathy. Heart Fail Rev 2019; 24:359-366. [DOI: 10.1007/s10741-018-09767-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Effect of Institutional Experience on Outcomes of Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy. Can J Cardiol 2018; 34:16-22. [PMID: 29275877 DOI: 10.1016/j.cjca.2017.10.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/25/2017] [Accepted: 10/25/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The current American College of Cardiology Foundation/American Heart Association guidelines on hypertrophic cardiomyopathy state that institutional experience is a key determinant of successful outcomes and lower complication rates of alcohol septal ablation (ASA). The aim of this study was to evaluate the safety and efficacy of ASA according to institutional experience with the procedure. METHODS We retrospectively evaluated 1310 patients with symptomatic obstructive hypertrophic cardiomyopathy who underwent ASA and were divided into 2 groups. The first-50 group consisted of the first consecutive 50 patients treated at each centre, and the over-50 group consisted of patients treated thereafter (patients 51 and above). RESULTS In the 30-day follow-up, there was a significant difference in the occurrence of major cardiovascular adverse events (21% in the first-50 group vs 12% in the over-50 group; P < 0.01), which was driven by the occurrence of cardiovascular deaths (2.1% vs 0.4%; P = 0.01) and implanted pacemakers (15% vs 9%; P < 0.01). In the long-term follow-up (5.5 ± 4.1 years), the first-50 group was associated with a significantly higher occurrence of major adverse events (P < 0.01) and higher cardiovascular mortality (P < 0.01). Also, patients in the first-50 group were more likely to self-report dyspnea of New York Heart Association class III/IV (16% vs 10%), to have a left ventricular outflow gradient > 30 mm Hg (16% vs 10%) at the last clinical check-up (P < 0.01 for both), and a probability of repeated septal reduction therapy (P = 0.03). CONCLUSIONS An institutional experience of > 50 ASA procedures was associated with a lower occurrence of ASA complications, better cardiovascular survival, better hemodynamic and clinical effect, and less need for repeated septal reduction therapy.
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Survival After Alcohol Septal Ablation in Patients With Hypertrophic Obstructive Cardiomyopathy. J Am Coll Cardiol 2018; 72:3087-3094. [DOI: 10.1016/j.jacc.2018.09.064] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/12/2018] [Accepted: 09/18/2018] [Indexed: 11/20/2022]
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Osman M, Kheiri B, Osman K, Barbarawi M, Alhamoud H, Alqahtani F, Alkhouli M. Alcohol septal ablation vs myectomy for symptomatic hypertrophic obstructive cardiomyopathy: Systematic review and meta-analysis. Clin Cardiol 2018; 42:190-197. [PMID: 30421437 DOI: 10.1002/clc.23113] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/25/2018] [Accepted: 11/08/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Surgical myectomy (SM) and Alcohol septal ablation (ASA) are effective therapies for patients with hypertrophic cardiomyopathy who remain symptomatic despite medical therapy. A plethora of data has recently emerged on the long-term outcomes of these procedures. We hence sought to perform an updated meta-analysis comparing both procedures. METHODS Studies reporting long-term (>3-years) outcomes of SM and/or ASA were included. The primary endpoint was all-cause mortality. Secondary endpoints included cardiovascular mortality, sudden cardiac death (SCD), reintervention, and complications including death, pacemaker implantation, and stroke. RESULTS Twenty-two ASA cohorts (n = 4213; follow-up = 6.6-years) and 23 SM cohorts (n = 4240; follow-up = 6.8-years) were included. Septal myectomy was associated with higher periprocedural mortality and stroke (2% vs 1.2%, P = 0.009 and 1.5% vs 0.8% P = 0.013, respectively), but ASA was associated with more need of pacemaker (10% vs 5%, P < 0.001). During long-term follow-up, all-cause mortality, cardiovascular mortality, and sudden cardiac death rates were 1.5%, 0.4%, and 0.3% per person-year in the ASA group and 1.1%, 0.5%, and 0.3% per person-year in the SM group (P = 0.21, P = 0.53, P = 0.43), respectively. Repeat septal reduction intervention(s) were more common after ASA (11% vs 1.5%, P < 0.001). CONCLUSION Compared with SM, ASA is associated with lower periprocedural mortality and stroke but higher rates of pacemaker implantations and reintervention. However, there was no difference between ASA and SM with regards to long-term all-cause mortality, cardiovascular mortality, or SCD.
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Affiliation(s)
- Mohammed Osman
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Babikir Kheiri
- Hurley Medical Center, Michigan State University, Flint, Michigan
| | | | | | - Hani Alhamoud
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Fahad Alqahtani
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Mohamad Alkhouli
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia
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Jensen MK, Faber L, Liebregts M, Januska J, Krejci J, Bartel T, Cooper RM, Dabrowski M, Hansen PR, Almaas VM, Seggewiss H, Horstkotte D, Adlova R, Berg JT, Bundgaard H, Veselka J. Effect of impaired cardiac conduction after alcohol septal ablation on clinical outcomes: insights from the Euro-ASA registry. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 5:252-258. [DOI: 10.1093/ehjqcco/qcy049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/05/2018] [Accepted: 10/08/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Aims
We analysed the impact of bundle branch block (BBB) and pacemaker (PM) implantation on symptoms and survival after alcohol septal ablation (ASA) in patients with hypertrophic cardiomyopathy (HCM).
Methods and results
Among 1416 HCM patients from the Euro-ASA registry, 58 (4%) patients had a PM and 64 (5%) patients had an implantable cardioverter-defibrillator (ICD) before ASA. At latest follow-up (5.0 ± 4.0 years) after ASA, 118 (8%) patients had an ICD and 229 (16%) patients had a PM. In patients without an implantable device prior to ASA 13% had a PM and 5% had an ICD implanted following ASA. New onset BBB was present in 44% (right BBB in 31%) of patients without previous BBB. At latest follow-up, we found no associations between BBB and New York Heart Association (NYHA) Class 3–4 [odds ratio (OR) 0.98, 95% confidence interval (CI) 0.63–1.51; P = 0.91] or Canadian Cardiovascular Society (CCS) Class 3–4 (OR 1.5, CI 0.32–6.7; P = 0.62), respectively, and no associations between PM and NYHA Class 3–4 (OR 1.2, CI 0.70–2.0; P = 0.52) or CCS 3–4 (OR 1.3, CI 0.24–6.6; P = 0.79), respectively. The survival after ASA was not reduced in patients with BBB [hazard ratio (HR) 0.73, CI 0.53–1.01; P = 0.06] or PM (HR 0.78, CI 0.52–1.17; P = 0.24).
Conclusions
Development of BBB or need for a PM after ASA in patients with obstructive HCM was not associated with inferior symptomatic outcome or reduced survival, thus concerns for the negative impact of impaired cardiac conduction on the clinical outcome after ASA were not confirmed.
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Affiliation(s)
- Morten Kvistholm Jensen
- Unit for Inherited Cardiac Diseases, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Lothar Faber
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Max Liebregts
- Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | | | - Jan Krejci
- 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Centre, St. Anne’s University Hospital and Masaryk University, Brno, Czech Republic
| | - Thomas Bartel
- Department of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
- Heart & Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Robert M Cooper
- Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Liverpool, England
| | - Maciej Dabrowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Peter Riis Hansen
- Department of Cardiology, Herlev and Gentofte Hospital, Hellerup, Denmark
| | | | | | - Dieter Horstkotte
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Radka Adlova
- Department of Cardiology, 2nd Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Jurriën ten Berg
- Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - Henning Bundgaard
- Unit for Inherited Cardiac Diseases, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Josef Veselka
- Department of Cardiology, 2nd Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
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Díez-López C, Salazar-Mendiguchía J. Clinical presentations of hypertrophic cardiomyopathy and implications for therapy. Glob Cardiol Sci Pract 2018; 2018:19. [PMID: 30393631 PMCID: PMC6209433 DOI: 10.21542/gcsp.2018.19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
[first paragraph of article]Hypertrophic cardiomyopathy (HCM) is diagnosed in the presence of left ventricular hypertrophy of ≥15 mm in adult index cases, or ≥13 mm in relatives of known affected patients, that is not solely explained by abnormal loading conditions. In children, the left ventricle (LV) wall thickness should be more than two standard deviations above the predicted population mean. The typical anatomo-pathological findings include myocyte hypertrophy, disarray, interstitial fibrosis and small-vessel disease. Although all the myocytes are supposed to be affected, pathological alterations are not uniformly distributed throughout the myocardium. Asymmetrical hypertrophy of the interventricular septum is the most commonly observed phenotype, but any pattern of hypertrophy is consistent with the diagnosis.
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Affiliation(s)
- Carles Díez-López
- Advanced Heart Failure and Heart Transplant Unit. Heart Institute. Bellvitge University Hospital. Barcelona, Spain
| | - Joel Salazar-Mendiguchía
- Health in Code. Cardiovascular Genetics Department. A Coruña, Spain.,Genetics Department. Universitat Autònoma de Barcelona, Spain
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Maekawa Y, Akita K, Takanashi S. Contemporary Septal Reduction Therapy in Drug-Refractory Hypertrophic Obstructive Cardiomyopathy. Circ J 2018; 82:1977-1984. [PMID: 29910224 DOI: 10.1253/circj.cj-18-0575] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Hypertrophic cardiomyopathy (HCM) is a complex and relatively common genetic cardiac disease that has been the subject of intense investigation for over 50 years. Most patients with HCM are asymptomatic, but some develop symptoms, often many years after the appearance of electrocardiographic or echocardiographic evidence of left ventricular hypertrophy. Symptoms due to the left ventricular outflow tract obstruction frequently worsen over time, requiring septal reduction therapy (SRT) despite optimal medical therapy. Percutaneous transluminal septal myocardial ablation (PTSMA) and surgical myectomy are collectively known as SRT. In this review, we will focus on the emerging concept and practical implication of SRT and the available evidence on either PTSMA or surgical myectomy in the literature.
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Affiliation(s)
| | - Keitaro Akita
- Internal Medicine III, Hamamatsu University School of Medicine
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Santos Mateo JJ, Sabater Molina M, Gimeno Blanes JR. Miocardiopatía hipertrófica. Med Clin (Barc) 2018; 150:434-442. [DOI: 10.1016/j.medcli.2017.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/04/2017] [Accepted: 09/05/2017] [Indexed: 02/07/2023]
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Seggewiß H, Koljaja-Batzner A, Seggewiß K, Meesmann M. [Syncope in hypertrophic (obstructive) cardiomyopathy]. Herzschrittmacherther Elektrophysiol 2018; 29:178-182. [PMID: 29761339 DOI: 10.1007/s00399-018-0567-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 04/03/2018] [Indexed: 11/24/2022]
Abstract
Hypertrophic cardiomyopathy is the most common genetic cardiac disease. The most important pathophysiological finding is dynamic (outflow tract) obstruction of the left ventricle in about 70% of affected patients. Especially in younger patients, an increased risk of sudden cardiac death has been observed. Syncope and presyncope-in addition to extremely variable cardiac symptoms (dyspnea and angina)-are common. The etiology of syncope is complex. The most important aspect for diagnosis is a detailed history regarding the accompanying circumstances of the syncope. In principle, an attempt must be made to distinguish between rhythmogenic and hemodynamic causes. Diagnostic work-up should be performed under the criteria of a possible prognostic-with implantation of an implantable cardioverter-defibrillator (ICD) in patients at increased risk of sudden cardiac death-and symptomatic therapy. Depending on the underlying morphology and the experience of the surgeon, percutaneous septal ablation and operative myectomy are complementary options for symptomatic treatment if medical therapy with beta-blockers and/or verapamil is inadequate.
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Affiliation(s)
- Hubert Seggewiß
- Standort Juliusspital, Medizinische Klinik - Kardiologie & Internistische Intensivmedizin, Klinikum Würzburg-Mitte, Juliuspromenade 19, 97070, Würzburg, Deutschland.
| | - Angelika Koljaja-Batzner
- Standort Juliusspital, Medizinische Klinik - Kardiologie & Internistische Intensivmedizin, Klinikum Würzburg-Mitte, Juliuspromenade 19, 97070, Würzburg, Deutschland
| | | | - Malte Meesmann
- Standort Juliusspital, Medizinische Klinik - Kardiologie & Internistische Intensivmedizin, Klinikum Würzburg-Mitte, Juliuspromenade 19, 97070, Würzburg, Deutschland
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34
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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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35
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Hypertrophic Cardiomyopathy-Past, Present and Future. J Clin Med 2017; 6:jcm6120118. [PMID: 29231893 PMCID: PMC5742807 DOI: 10.3390/jcm6120118] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 11/21/2017] [Accepted: 12/05/2017] [Indexed: 12/15/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy with a prevalence of 1 in 500 in the general population. Since the first pathological case series at post mortem in 1957, we have come a long way in its understanding, diagnosis and management. Here, we will describe the history of our understanding of HCM including the initial disease findings, diagnostic methods and treatment options. We will review the current guidelines for the diagnosis and management of HCM, current gaps in the evidence base and discuss the new and promising developments in this field.
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36
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Jensen MK, Jacobsson L, Almaas V, van Buuren F, Hansen PR, Hansen TF, Aakhus S, Eriksson MJ, Bundgaard H, Faber L. Influence of Septal Thickness on the Clinical Outcome After Alcohol Septal Alation in Hypertrophic Cardiomyopathy. Circ Cardiovasc Interv 2017; 9:CIRCINTERVENTIONS.115.003214. [PMID: 27217377 DOI: 10.1161/circinterventions.115.003214] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 04/14/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND We assessed the influence of interventricular septal thickness (IVSd) on the clinical outcome and survival after alcohol septal ablation (ASA) in patient with hypertrophic cardiomyopathy. METHODS AND RESULTS We analyzed 531 patients with hypertrophic cardiomyopathy (age: 56±14 years, men 55%) treated with ASA. Survival status was obtained 7.9±4.0 years after ASA. Baseline IVSd was inversely associated with survival (hazard ratio [HR] for 1 mm increment, 1.13; confidence interval, 1.05-1.21; P<0.001) after adjustment for age, sex, body mass index, and ASA-performing center. Compared with patients with baseline IVSd <20 mm, patients with baseline IVSd ≥25 mm had reduced survival (HR, 5.0; CI, 2.1-12), whereas patients with baseline IVSd 20 to 24 mm had similar survival (HR, 1.4; CI, 0.7-2.8). Baseline IVSd was not correlated with New York Heart Association class, Canadian Cardiology Society class, or syncope. Clinical outcome was assessed 0.6±0.6 years after ASA. IVSd was not related to left ventricular outflow tract gradient reduction at rest (P=0.883) or during Valsalva maneuver (P=0.885). The proportion of patients in New York Heart Association class 3 to 4 was reduced from 86% to 10%; in Canadian Cardiology Society class 3 to 4 from 26% to 2%; and with syncope from 25% to 2%. There were no correlations between baseline IVSd and New York Heart Association class (P=0.067), Canadian Cardiology Society class (P=0.106), or syncope (P=0.426) after ASA. CONCLUSIONS ASA had equal effects on left ventricular outflow tract gradients and symptoms throughout the spectrum of septal hypertrophy. Severe septal hypertrophy before ASA remained a marker of reduced survival after ASA with a 5-fold increased risk of all-cause mortality in patients with baseline IVSd >25 mm compared with patients with baseline IVSd <20 mm.
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Affiliation(s)
- Morten K Jensen
- From the Unit for Inherited Heart Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (M.K.J., H.B.); Karolinska University Hospital, Stockholm, Sweden (L.J., M.J.E.); Oslo University Hospital, Rikshospitalet, Oslo, Norway (V.A., S.A.); Heart and Diabetes Center NRW, Bad Oeynhausen, Germany (F.v.B., L.F.); and Gentofte Hospital, Hellerup, Denmark (P.R.H., T.F.H.).
| | - Linda Jacobsson
- From the Unit for Inherited Heart Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (M.K.J., H.B.); Karolinska University Hospital, Stockholm, Sweden (L.J., M.J.E.); Oslo University Hospital, Rikshospitalet, Oslo, Norway (V.A., S.A.); Heart and Diabetes Center NRW, Bad Oeynhausen, Germany (F.v.B., L.F.); and Gentofte Hospital, Hellerup, Denmark (P.R.H., T.F.H.)
| | - Vibeke Almaas
- From the Unit for Inherited Heart Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (M.K.J., H.B.); Karolinska University Hospital, Stockholm, Sweden (L.J., M.J.E.); Oslo University Hospital, Rikshospitalet, Oslo, Norway (V.A., S.A.); Heart and Diabetes Center NRW, Bad Oeynhausen, Germany (F.v.B., L.F.); and Gentofte Hospital, Hellerup, Denmark (P.R.H., T.F.H.)
| | - Frank van Buuren
- From the Unit for Inherited Heart Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (M.K.J., H.B.); Karolinska University Hospital, Stockholm, Sweden (L.J., M.J.E.); Oslo University Hospital, Rikshospitalet, Oslo, Norway (V.A., S.A.); Heart and Diabetes Center NRW, Bad Oeynhausen, Germany (F.v.B., L.F.); and Gentofte Hospital, Hellerup, Denmark (P.R.H., T.F.H.)
| | - Peter R Hansen
- From the Unit for Inherited Heart Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (M.K.J., H.B.); Karolinska University Hospital, Stockholm, Sweden (L.J., M.J.E.); Oslo University Hospital, Rikshospitalet, Oslo, Norway (V.A., S.A.); Heart and Diabetes Center NRW, Bad Oeynhausen, Germany (F.v.B., L.F.); and Gentofte Hospital, Hellerup, Denmark (P.R.H., T.F.H.)
| | - Thomas F Hansen
- From the Unit for Inherited Heart Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (M.K.J., H.B.); Karolinska University Hospital, Stockholm, Sweden (L.J., M.J.E.); Oslo University Hospital, Rikshospitalet, Oslo, Norway (V.A., S.A.); Heart and Diabetes Center NRW, Bad Oeynhausen, Germany (F.v.B., L.F.); and Gentofte Hospital, Hellerup, Denmark (P.R.H., T.F.H.)
| | - Svend Aakhus
- From the Unit for Inherited Heart Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (M.K.J., H.B.); Karolinska University Hospital, Stockholm, Sweden (L.J., M.J.E.); Oslo University Hospital, Rikshospitalet, Oslo, Norway (V.A., S.A.); Heart and Diabetes Center NRW, Bad Oeynhausen, Germany (F.v.B., L.F.); and Gentofte Hospital, Hellerup, Denmark (P.R.H., T.F.H.)
| | - Maria J Eriksson
- From the Unit for Inherited Heart Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (M.K.J., H.B.); Karolinska University Hospital, Stockholm, Sweden (L.J., M.J.E.); Oslo University Hospital, Rikshospitalet, Oslo, Norway (V.A., S.A.); Heart and Diabetes Center NRW, Bad Oeynhausen, Germany (F.v.B., L.F.); and Gentofte Hospital, Hellerup, Denmark (P.R.H., T.F.H.)
| | - Henning Bundgaard
- From the Unit for Inherited Heart Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (M.K.J., H.B.); Karolinska University Hospital, Stockholm, Sweden (L.J., M.J.E.); Oslo University Hospital, Rikshospitalet, Oslo, Norway (V.A., S.A.); Heart and Diabetes Center NRW, Bad Oeynhausen, Germany (F.v.B., L.F.); and Gentofte Hospital, Hellerup, Denmark (P.R.H., T.F.H.)
| | - Lothar Faber
- From the Unit for Inherited Heart Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (M.K.J., H.B.); Karolinska University Hospital, Stockholm, Sweden (L.J., M.J.E.); Oslo University Hospital, Rikshospitalet, Oslo, Norway (V.A., S.A.); Heart and Diabetes Center NRW, Bad Oeynhausen, Germany (F.v.B., L.F.); and Gentofte Hospital, Hellerup, Denmark (P.R.H., T.F.H.)
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Abstract
Hypertrophic cardiomyopathy is a genetic disorder characterized by marked hypertrophy of the myocardium. It is frequently accompanied by dynamic left ventricular outflow tract obstruction and symptoms of dyspnea, angina, and syncope. The initial therapy for symptomatic patients with obstruction is medical therapy with β-blockers and calcium antagonists. However, there remain a subset of patients who have continued severe symptoms, which are unresponsive to medical therapy. These patients can be treated with septal reduction therapy, either surgical septal myectomy or alcohol septal ablation. When performed by experienced operators working in high-volume centers, septal myectomy is highly effective with a >90% relief of obstruction and improvement in symptoms. The perioperative mortality rate for isolated septal myectomy in most centers is <1%. Alcohol septal ablation is a less invasive treatment. In many patients, the hemodynamic and clinical results are comparable to that of septal myectomy. However, the results of alcohol septal ablation are dependent on the septal perforator artery supplying the area of the contact between the hypertrophied septum and the anterior leaflet of the mitral valve. There are some patients, particularly younger patients with severe hypertrophy, who do not uniformly experience complete relief of obstruction and symptoms. Both techniques of septal reduction therapy are highly operator dependent. The final decision as to which approach should be selected in any given patient is dependent up patient preference and the availability and experience of the operator and institution at which the patient is being treated.
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Affiliation(s)
- Rick A Nishimura
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (R.A.N.); Medizinische Klinik 1, Leopoldina Krankenhaus, Schweinfurt, Germany (H.S.); and Department of Cardiovascular Surgery, Rochester, MN (H.V.S.).
| | - Hubert Seggewiss
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (R.A.N.); Medizinische Klinik 1, Leopoldina Krankenhaus, Schweinfurt, Germany (H.S.); and Department of Cardiovascular Surgery, Rochester, MN (H.V.S.)
| | - Hartzell V Schaff
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (R.A.N.); Medizinische Klinik 1, Leopoldina Krankenhaus, Schweinfurt, Germany (H.S.); and Department of Cardiovascular Surgery, Rochester, MN (H.V.S.)
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Cooper RM, Raphael CE, Liebregts M, Anavekar NS, Veselka J. New Developments in Hypertrophic Cardiomyopathy. Can J Cardiol 2017; 33:1254-1265. [DOI: 10.1016/j.cjca.2017.07.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 07/04/2017] [Accepted: 07/11/2017] [Indexed: 01/22/2023] Open
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Sorajja P. Alcohol Septal Ablation for Obstructive Hypertrophic Cardiomyopathy: A Word of Balance. J Am Coll Cardiol 2017; 70:489-494. [PMID: 28728695 DOI: 10.1016/j.jacc.2017.06.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 06/05/2017] [Accepted: 06/05/2017] [Indexed: 11/29/2022]
Abstract
The management of drug-refractory symptoms of obstructive hypertrophic cardiomyopathy has long been debated and is primarily centered on the choice between surgical myectomy and alcohol septal ablation. Decision making in these patients requires consideration of procedural risk, expertise and efficacy, and the long-term impact on patients' survival. Although there have been numerous reports on these procedures that may help guide decision making, these data continue to be self-reported and voluntary. Greater insight into the real-world experience for these therapies and how they should be applied in practice would be gained from mandatory reporting, akin to other multidisciplinary, transcatheter-based therapies.
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Affiliation(s)
- Paul Sorajja
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota.
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An SY, Yang YJ, Hang F, Wang ZM, Fan CM. Procedural complication and long term outcomes after alcohol septal ablation in patients with obstructive hypertrophic cardiomyopathy: data from China. Sci Rep 2017; 7:9506. [PMID: 28842653 PMCID: PMC5572739 DOI: 10.1038/s41598-017-10144-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 07/27/2017] [Indexed: 11/24/2022] Open
Abstract
Data on procedural complications and long term survival after alcohol septal ablation (ASA) in Chinese patients with obstructive hypertrophic cardiomyopathy (HOCM) are lacking. We aimed to investigate long-term survival of HOCM patients after ASA and compared to the non-obstructive hypertrophic cardiomyopathy(NOHCM). A total of 233 patients with HOCM and a peak pressure gradient of ≥50 mm Hg at rest or with provocation were consecutively enrolled from Fuwai Hospital in China between 2000 and 2012. Another 297 patients without left ventricular outflow tract obstruction were regarded as control group. Periprocedural mortality of ASA were low (0.89%). Periprocedural lethal ventricular arrhythmia occurred in 9 patients (4.0%). Alcohol volume (RR 1.44, 95% CI: 1.03–2.03, P = 0.034) and age ≤40 years old (RR 4.63, 95% CI: 1.07–20.0, P = 0.040) were independent predictors for periprocedural lethal ventricular arrhythmia. The 10- year overall survival was 94.6% in the ASA group, similar with 92.9% in the NOHCM group (P = 0.930). In conclusion, periprocedural mortality and complications were rare in ASA. Long term survival after ASA were satisfactory and comparable to NOHCM. Patients under 40 years old should be more cautious undergoing ASA, for these patients were more likely to endure lethal ventricular arrhythmia during periprocedural period of ASA.
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Affiliation(s)
- Shuo-Yan An
- Key Laboratory of Clinical Trial Research in Cardiovascular Drugs, Ministry of Health, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yin-Jian Yang
- Key Laboratory of Clinical Trial Research in Cardiovascular Drugs, Ministry of Health, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Hang
- Key Laboratory of Clinical Trial Research in Cardiovascular Drugs, Ministry of Health, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Min Wang
- Department of Ultrasound, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chao-Mei Fan
- Key Laboratory of Clinical Trial Research in Cardiovascular Drugs, Ministry of Health, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Veselka J, Faber L, Liebregts M, Cooper R, Januska J, Krejci J, Bartel T, Dabrowski M, Hansen PR, Almaas VM, Seggewiss H, Horstkotte D, Adlova R, Bundgaard H, Ten Berg J, Stables RH, Jensen MK. Outcome of Alcohol Septal Ablation in Mildly Symptomatic Patients With Hypertrophic Obstructive Cardiomyopathy: A Long-Term Follow-Up Study Based on the Euro-Alcohol Septal Ablation Registry. J Am Heart Assoc 2017; 6:JAHA.117.005735. [PMID: 28512112 PMCID: PMC5524107 DOI: 10.1161/jaha.117.005735] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The long‐term efficacy and safety of alcohol septal ablation (ASA) in patients with highly symptomatic hypertrophic obstructive cardiomyopathy has been demonstrated. The aim of this study was to evaluate the long‐term outcomes of mildly symptomatic patients with hypertrophic obstructive cardiomyopathy treated with ASA. Methods and Results We retrospectively evaluated consecutive patients enrolled in the Euro‐ASA registry (1427 patients) and identified 161 patients (53±13 years; 27% women) who were mildly symptomatic (New York Heart Association [NYHA] class II) pre‐ASA. The median (interquartile range) follow‐up was 4.8 (1.7–8.5) years. The clinical outcome was assessed and compared with the age‐ and sex‐matched general population. The 30‐day mortality after ASA was 0.6% and the annual all‐cause mortality rate was 1.7%, which was similar to the age‐ and sex‐matched general population (P=0.62). A total of 141 (88%) patients had resting left ventricular outflow tract gradient at the last clinical checkup ≤30 mm Hg. Obstruction was reduced from 63±32 to 15±19 mm Hg (P<0.01), and the mean NYHA class decreased from 2.0±0 to 1.3±0.1 (P<0.01); 69%, 29%, and 2% of patients were in NYHA class I, II, and III at the last clinical checkup, respectively. Conclusions Mildly symptomatic hypertrophic obstructive cardiomyopathy patients treated with ASA had sustained symptomatic and hemodynamic relief with a low risk of developing severe heart failure. Their survival is comparable to the general population.
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Affiliation(s)
- Josef Veselka
- Department of Cardiology, 2nd Medical School, Charles University University Hospital Motol, Prague, Czech Republic
| | - Lothar Faber
- Department of Cardiology, Heart and Diabetes Centre NRW, Ruhr-University Bochum, Bad Oyenhausen, Germany
| | - Max Liebregts
- Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - Robert Cooper
- Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Liverpool, England
| | | | - Jan Krejci
- 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Centre, St. Anne's University Hospital and Masaryk University, Brno, Czech Republic
| | - Thomas Bartel
- Department of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria.,Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Maciej Dabrowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Peter Riis Hansen
- Department of Cardiology, Gentofte Hospital, Copenhagen University Hospital, Hellerup, Denmark
| | - Vibeke Marie Almaas
- Department of Cardiology, Heart and Diabetes Centre NRW, Ruhr-University Bochum, Bad Oyenhausen, Germany.,Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | | | - Dieter Horstkotte
- Department of Cardiology, Heart and Diabetes Centre NRW, Ruhr-University Bochum, Bad Oyenhausen, Germany
| | - Radka Adlova
- Department of Cardiology, 2nd Medical School, Charles University University Hospital Motol, Prague, Czech Republic
| | - Henning Bundgaard
- Unit for Inherited Cardiac Diseases, Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jurriën Ten Berg
- Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - Rodney Hilton Stables
- Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Liverpool, England
| | - Morten Kvistholm Jensen
- Unit for Inherited Cardiac Diseases, Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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43
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Veselka J, Anavekar NS, Charron P. Hypertrophic obstructive cardiomyopathy. Lancet 2017; 389:1253-1267. [PMID: 27912983 DOI: 10.1016/s0140-6736(16)31321-6] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/22/2016] [Accepted: 08/02/2016] [Indexed: 12/23/2022]
Abstract
Hypertrophic obstructive cardiomyopathy is an inherited myocardial disease defined by cardiac hypertrophy (wall thickness ≥15 mm) that is not explained by abnormal loading conditions, and left ventricular obstruction greater than or equal to 30 mm Hg. Typical symptoms include dyspnoea, chest pain, palpitations, and syncope. The diagnosis is usually suspected on clinical examination and confirmed by imaging. Some patients are at increased risk of sudden cardiac death, heart failure, and atrial fibrillation. Patients with an increased risk of sudden cardiac death undergo cardioverter-defibrillator implantation; in patients with severe symptoms related to ventricular obstruction, septal reduction therapy (myectomy or alcohol septal ablation) is recommended. Life-long anticoagulation is indicated after the first episode of atrial fibrillation.
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Affiliation(s)
- Josef Veselka
- Department of Cardiology, 2nd Medical School, Charles University and Motol University Hospital, Prague, Czech Republic.
| | - Nandan S Anavekar
- Departments of Cardiology and Radiology, Mayo Clinic, Rochester, MN, USA
| | - Philippe Charron
- Université Paris Sud, UVSQ, INSERM U1018, CESP, Boulogne-Billancourt, France; APHP, ICAN, Hôpital de la Pitié Salpêtrière, Paris, France
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44
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Rigopoulos AG, Seggewiss H. Twenty Years of Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy. Curr Cardiol Rev 2016; 12:285-296. [PMID: 25563291 PMCID: PMC5304253 DOI: 10.2174/1573403x11666150107160344] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 12/14/2014] [Accepted: 12/17/2014] [Indexed: 01/28/2023] Open
Abstract
Hypertrophic obstructive cardiomyopathy is the most common genetic cardiac disease and is generally characterised by asymmetric septal hypertrophy and intraventricular obstruction. Patients with severe obstruction and significant symptoms that persist despite optimal medical treatment are candidates for an invasive septal reduction therapy. Twenty years after its introduction, percutaneous transluminal alcohol septal ablation has been increasingly preferred for septal reduction in patients with drug refractory hypertrophic obstructive cardiomyopathy. Myocardial contrast echocardiography and injection of reduced alcohol volumes have increased safety, while efficacy is comparable to the surgical alternative, septal myectomy, which has for decades been regarded as the 'gold standard' treatment. Data on medium- and long-term survival show improved prognosis with survival being similar to the general population. Current guidelines have supported its use by experienced operators in centres specialised in the treatment of patients with hypertrophic obstructive cardiomyopathy.
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Affiliation(s)
- Angelos G Rigopoulos
- Medizinische Klinik 1, Leopoldina Krankenhaus Schweinfurt, Gustav-Adolf-Str. 8, 97422 Schweinfurt, Germany.
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45
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Veselka J, Tomašov P, Januška J, Krejčí J, Adlová R. Obstruction after alcohol septal ablation is associated with cardiovascular mortality events. Heart 2016; 102:1793-1796. [PMID: 27587438 DOI: 10.1136/heartjnl-2016-309699] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 05/25/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Left ventricular outflow tract obstruction (≥30 mm Hg at rest; LVOTO) is considered a possible risk of long-term outcomes in patients with hypertrophic cardiomyopathy (HCM). However, the influence of LVOTO on the occurrence of cardiovascular mortality events in patients after alcohol septal ablation (ASA) for obstructive HCM remains unresolved. METHODS We compared the outcomes of patients treated with ASA with residual LVOTO <30 mm Hg with those with residual LVOTO ≥30 mm Hg at the first postdischarge check-up (1-6 months after the procedure). RESULTS A total of 270 patients (60±12 years, median follow-up 5.1 years; 95% CI 4.5 to 5.9 years) treated with a single ASA were included; 208 (77%) and 62 (23%) patients had post-ASA LVOTO <30 and ≥30 mm Hg at the first postdischarge clinical check-up, respectively (LVOTO 13±6 vs 50±27 mm Hg; p<0.01). Freedom from cardiovascular mortality events at 1, 5 and 10 years were 99% (95% CI 96% to 100%) vs 94% (95% CI 85% to 98%), 95% (95% CI 89% to 97%) vs 80% (95% CI 66% to 89%) and 82% (95% CI 69% to 89%) vs 72% (95% CI 55% to 84%) (log-rank test, p<0.01), respectively. In multivariable analysis adjusted for age at ASA, sex, baseline LVOTO and baseline septum thickness, the independent predictors of cardiovascular mortality events were early postdischarge LVOTO ≥30 mm Hg (HR 2.95, 95% CI 1.26 to 6.91; p=0.01) and baseline septum thickness (HR 1.07, 95% CI 1.01 to 1.13; p=0.02). CONCLUSIONS After ASA for obstructive HCM, LVOTO ≥30 mm Hg at the first postdischarge clinical check-up is associated with significantly higher occurrence of subsequent cardiovascular mortality events.
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Affiliation(s)
- Josef Veselka
- Department of Cardiology, 2nd Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Pavol Tomašov
- Department of Cardiology, 2nd Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Jaroslav Januška
- Department of Cardiology, Cardiocentre Podlesí, Třinec, Czech Republic
| | - Jan Krejčí
- 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Centre, St Anne's University Hospital and Masaryk University, Brno, Czech Republic
| | - Radka Adlová
- Department of Cardiology, 2nd Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
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Chothani A, Panaich SS, Patel N, Patel NJ, Arora S, Deshmukh A, Grines C, Badheka AO. Septal Ablation and Hypertrophic Obstructive Cardiomyopathy: 7 Years US Experience. J Interv Cardiol 2016; 29:505-512. [DOI: 10.1111/joic.12319] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Ankit Chothani
- Mount Sinai St. Luke's Roosevelt Hospital; New York New York
| | | | - Nilay Patel
- Saint Peter's University Hospital; New Brunswick New Jersey
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Bader Y, Kimmelstiel C. Ablation or surgery for medically refractory HCM. Updating an imperfect dataset. Catheter Cardiovasc Interv 2016; 88:116-7. [PMID: 27400639 DOI: 10.1002/ccd.26641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 06/04/2016] [Indexed: 11/07/2022]
Abstract
Retrospective comparison of alcohol septal ablation with surgical myectomy suggests that although there is a greater reduction in LVOT gradient with surgical myectomy, symptom relief and survival are similar between the two treatment strategies. In patients who don't have an anatomic indication for surgical myectomy, alcohol septal ablation appears to be a safe and effective alternative. Patients with medication-refractory HOCM require a multi-disciplinary assessment, which is best performed at specialized treatment centers, to assess which therapy is best suited to treat them.
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Affiliation(s)
- Yousef Bader
- Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Carey Kimmelstiel
- Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts.,Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts
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Rigopoulos AG, Daci S, Pfeiffer B, Papadopoulou K, Neugebauer A, Seggewiss H. Low occurrence of ventricular arrhythmias after alcohol septal ablation in high-risk patients with hypertrophic obstructive cardiomyopathy. Clin Res Cardiol 2016; 105:953-961. [PMID: 27270758 DOI: 10.1007/s00392-016-1005-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 05/31/2016] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Percutaneous alcohol septal ablation (PTSMA) is an established treatment for symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). However, there is concern of a higher risk for ventricular tachyarrhythmias and sudden death due to the myocardial scar created after PTSMA. We investigated the possibility of increased ventricular arrhythmias and risk of sudden death after PTSMA in a subgroup of patients with an already implanted ICD. METHODS AND RESULTS Between 2009 and 2012, 239 PTSMAs were performed in 212 patients with HOCM. In 32 of those an ICD had already been implanted before PTSMA for primary (31 patients) or secondary (1 patient) prevention of sudden death. The maximum left ventricular outflow tract gradient (LVOTG) was reduced from 114 ± 39 mmHg before PTSMA to 23 ± 19 mmHg (P < 0.0001). Among clinical risk factors for sudden death, nonsustained ventricular tachycardia (VT), syncope and family history for sudden death were most common. After a median follow-up of 5.3 (IQR 4.3-5.7) years after PTSMA only one patient had ICD shocks (annual ICD discharge 0.6 %). In another 3 patients, with already documented nonsustained VTs as risk factor before ICD implantation, VT episodes that activated antitachycardic pacing were recorded. The annual appropriate ICD intervention including all events was 2.5 % and involved only patients with a very high estimated 5-year sudden death risk before PTSMA (>14.3 %). CONCLUSIONS In a selected high-risk patient cohort with HOCM ominous arrhythmic events seem to be rare and predominantly occur in patients with a very high estimated risk of sudden death before PTSMA.
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MESH Headings
- Ablation Techniques/adverse effects
- Adolescent
- Adult
- Aged
- Cardiomyopathy, Hypertrophic/complications
- Cardiomyopathy, Hypertrophic/diagnosis
- Cardiomyopathy, Hypertrophic/mortality
- Cardiomyopathy, Hypertrophic/surgery
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Electric Countershock/instrumentation
- Ethanol/administration & dosage
- Ethanol/adverse effects
- Female
- Germany
- Humans
- Male
- Middle Aged
- Retrospective Studies
- Risk Factors
- Tachycardia, Ventricular/diagnosis
- Tachycardia, Ventricular/etiology
- Tachycardia, Ventricular/mortality
- Tachycardia, Ventricular/therapy
- Time Factors
- Treatment Outcome
- Ventricular Outflow Obstruction/diagnosis
- Ventricular Outflow Obstruction/etiology
- Ventricular Outflow Obstruction/mortality
- Ventricular Outflow Obstruction/surgery
- Young Adult
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Affiliation(s)
- Angelos G Rigopoulos
- 1st Department of Internal Medicine, Leopoldina Hospital, Gustav-Adolf-Str. 8, 97422, Schweinfurt, Germany.
| | - Silke Daci
- 1st Department of Internal Medicine, Leopoldina Hospital, Gustav-Adolf-Str. 8, 97422, Schweinfurt, Germany
| | - Barbara Pfeiffer
- 1st Department of Internal Medicine, Leopoldina Hospital, Gustav-Adolf-Str. 8, 97422, Schweinfurt, Germany
| | - Konstadia Papadopoulou
- 1st Department of Internal Medicine, Leopoldina Hospital, Gustav-Adolf-Str. 8, 97422, Schweinfurt, Germany
| | - Anna Neugebauer
- 1st Department of Internal Medicine, Leopoldina Hospital, Gustav-Adolf-Str. 8, 97422, Schweinfurt, Germany
| | - Hubert Seggewiss
- 1st Department of Internal Medicine, Leopoldina Hospital, Gustav-Adolf-Str. 8, 97422, Schweinfurt, Germany
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50
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Relationship of basal-septal fibrosis with LV outflow tract obstruction in hypertrophic cardiomyopathy: insights from cardiac magnetic resonance analysis. Int J Cardiovasc Imaging 2015; 32:613-20. [PMID: 26589516 DOI: 10.1007/s10554-015-0806-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 11/15/2015] [Indexed: 01/20/2023]
Abstract
Myocardial fibrosis is frequently observed and may be associated with the prognosis in patients with hypertrophic cardiomyopathy (HCM); however, the clinical pathophysiological features, particularly in terms of fibrosis, of hypertrophic obstructive cardiomyopathy (HOCM) remain unclear. This study aimed to determine a role of local fibrosis in HOCM using cardiac magnetic resonance (CMR). 108 consecutive HCM patients underwent CMR. HOCM was defined as a left ventricular outflow tract (LVOT) pressure gradient ≥30 mmHg at rest. Myocardial mass and fibrosis mass by late gadolinium-enhancement CMR (LGE-CMR) were calculated and the distribution/pattern was analyzed using the AHA 17-segment model. LV ejection fraction (LVEF) was significantly higher in patients with HOCM (n = 19) than in those with nonobstructive HCM (n = 89) (P < 0.05). Both total myocardial and fibrosis masses in LV were similar in the two groups (P = 0.385 and P = 0.859, respectively). However, fibrosis in the basal septum was significantly less frequent in the HOCM group than in the nonobstructive HCM group (P < 0.01). The LVOT pressure gradient was significantly higher in the basal-septal non-fibrosis group than in the fibrosis group (23.6 ± 37.3 vs. 4.8 ± 11.4 mmHg, P < 0.01). Multivariate analysis revealed that basal-septal fibrosis was an independent negative predictor of LVOT obstruction in addition to the local wall thickness and LVEF as positive predictors in HCM patients. In conclusion, a significant association was observed between LVOT obstruction and basal septal fibrosis by LGE-CMR in HCM patients. In addition to negative impact of basal-septal fibrosis, basal-septal hypertrophy and preserved global LV contractility may be associated with the pathophysiological features of LVOT obstruction.
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