Percutaneous alcohol septal ablation for hypertrophic obstructive cardiomyopathy: technical review and long-term clinical and echocardiographic outcomes.

BACKGROUND: Percutaneous septal ablation by alcohol-induced septal branch occlusion was introduced as a new treatment option in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). Our aim was to evaluate procedural and long-term clinical and echocardiographic outcomes in patients with HOCM treated by alcohol septal ablation (ASA) at our center. METHODS: This single-center retrospective study included 14 consecutive HOCM patients undergoing percutaneous ASA (66.4 +/- 12.1 years, 71.4% female). At baseline all patients presented persistent symptoms despite optimized medical treatment, left ventricular outflow tract (LVOT) obstruction with a peak gradient > 50 mmHg, systolic anterior motion of the mitral valve, and ventricular septal thickness > or = 15 mm. ASA was considered successful when the LVOT pressure gradient fell to less than 50% of baseline value. All patients had echocardiographic evaluation at baseline, intraprocedure and at follow-up, and a long-term clinical follow-up (25 +/- 38 months) with evaluation of functional class and occurrence of symptoms or cardiovascular events. RESULTS: Percutaneous ASA achieved a 71.4% acute and 85.7% long-term success rate. Peak LVOT gradient decreased from 104 +/- 40 mmHg at baseline to 58 +/- 30 mmHg intraprocedure (p = 0.03) and 35 +/- 26 mmHg at follow-up (p = 0.001); total gradient decrease was 75 +/- 43 mmHg. Ventricular septal thickness and mitral regurgitation also presented significant decreases during follow-up (from 24 +/- 5 mm to 18 +/- 4 mm, p = 0.02, and from grade 2.4 +/- 0.6 to 1.4 +/- 0.5, p < 0.001, respectively). A tendency for long-term improvement in NYHA functional class (from 2.6 +/- 1.1 to 1.8 +/- 1.4, p = 0.09) was observed. Procedural complications occurred in 6.7% of patients; two deaths and one transient ischemic attack occurred in-hospital, but no long-term clinical events were recorded. CONCLUSIONS: Percutaneous ASA is an effective treatment for symptomatic patients with HOCM, obtaining a marked decrease in LVOT pressure gradient and symptomatic improvement. Despite the occurrence of a significant number of procedural complications, the favorable long-term outcomes underline the potential of ASA as a percutaneous alternative to surgical myectomy.

Clinical and angiographic characteristics of patients with acute coronary syndrome associated with sudden cardiac death.

INTRODUCTION: Sudden death (SD) is in most cases due to cardiac causes, mainly secondary to ischemic heart disease. However, the angiographic characteristics in SD survivors in the context of an acute coronary syndrome (ACS) remain controversial. The aim of this study was to evaluate the clinical and angiographic characteristics of patients who suffered cardiac arrest during an ACS. METHODS: We evaluated 46 patients with SD related to ACS, who were divided into two groups according to their presentation: an ST-elevation myocardial infarction (SD-STEMI) group and a non ST-elevation myocardial infarction (SD-NSTEMI) group. Consecutive STEMI patients without SD served as a double size-matched control group. We compared the clinical and angiographic characteristics and the in-hospital mortality between groups. RESULTS: Patients in the SD-NSTEMI group (n=13) were older and had a higher incidence of hypertension. The left anterior descending coronary artery was the most frequent culprit vessel in all groups. SD-STEMI patients (n=33) had a higher prevalence of proximal coronary culprit segment involvement than did the nonSD STEMI group (75% vs. 36.3%, p<0.001). The SD-NSTEMI group was characterized by multivessel and multi-segment disease. Outcomes were similar for both SD groups. CONCLUSION: SD in patients with NSTEMI occurred in patients who were older, with more cardiovascular risk factors, diffuse and multivessel coronary disease, complex coronary lesions, and a lower rate of angioplasty success as compared with the STEMI group. SD STEMI patients had a significant higher association with proximal coronary acute occlusion than STEMI patients without SD.