Long-Term Outcome of Alcohol Septal Ablation for Obstructive Hypertrophic Cardiomyopathy in the Young and the Elderly.

OBJECTIVES: The aim of this study was to compare outcomes of alcohol septal ablation (ASA) in young and elderly patients with obstructive hypertrophic cardiomyopathy (HCM). BACKGROUND: The American College of Cardiology Foundation/American Heart Association guidelines reserve ASA for elderly patients and patients with serious comorbidities. Information on long-term age-specific outcomes after ASA is scarce. METHODS: This cohort study included 217 HCM patients (age 54 ± 12 years) who underwent ASA because of symptomatic left ventricular outflow tract obstruction. Patients were divided into young (age ≤55 years) and elderly (age >55 years) groups and matched by age in a 1:1 fashion to nonobstructive HCM patients. RESULTS: Atrioventricular block following ASA was more common in elderly patients (43% vs. 21%; p = 0.001), resulting in pacemaker implantation in 13% and 5%, respectively (p = 0.06). Residual left ventricular outflow tract gradient, post-procedural New York Heart Association functional class, and necessity for additional septal reduction therapy was comparable between age groups. During a follow-up of 7.6 ± 4.6 years, 54 patients died. The 5- and 10-year survival following ASA was 95% and 90% in patients age ≤55 years and 93% and 82% in patients age >55 years, which was comparable to their control groups. The annual adverse arrhythmic event rate following ASA was 0.7%/year in young patients and 1.4%/year in elderly patients, which was comparable to their control groups. CONCLUSIONS: ASA is similarly effective for reduction of symptoms in young and elderly patients; however, younger patients have a lower risk of procedure-related atrioventricular conduction disturbances. The long-term mortality rate and risk of adverse arrhythmic events following ASA are low, both in young and elderly patients, and are comparable to age-matched nonobstructive HCM patients.

Effect of alcohol dosage on long-term outcomes after alcohol septal ablation in patients with hypertrophic cardiomyopathy.

OBJECTIVES: The aim of this study is to assess the long-term effects of alcohol dosage in alcohol septal ablation (ASA) on mortality and adverse arrhythmic events (AAE). BACKGROUND: ASA can be performed to reduce left ventricular outflow tract (LVOT) obstruction in patients with hypertrophic cardiomyopathy (HCM). However, the effect of alcohol dosage on long-term outcomes is unknown. METHODS: This retrospective cohort study includes 296 HCM patients (age 60 ± 22 years, 58% male) who underwent ASA because of symptomatic LVOT obstruction. Twenty-nine patients (9.8%) were excluded because the alcohol dosage could not be retrieved. Primary endpoints were all-cause mortality and AAE. RESULTS: During 6.3 ± 3.7 years of follow-up, all-cause mortality and AAE rates were similar in patients who received ≤2.0 mL (n = 142) and >2.0 mL (n = 121) alcohol during ASA. Age was the only independent predictor of mortality (HR 1.1 95% CI 1.0-1.1, P < 0.001). Predictors of AAE were maximum CK-MB >240 U/L (HR 3.3 95% CI 1.5-7.2, P = 0.003), and sudden cardiac death survivor (HR 5.9 95% CI 1.7-20.3, P = 0.004). There was a mild to moderate correlation between CK-MB levels and amount of alcohol (Spearman's ρ 0.39, P < 0.001), cross-sectional area of the target septal branch ostium/ostia (Spearman's ρ 0.19, P = 0.003), and maximum ventricular wall thickness (Spearman's ρ 0.17, P = 0.006). CONCLUSIONS: Alcohol dosage appears not to have a long-term effect on mortality and AAE. A larger infarct size created by ASA increases the risk of AAE, and extended monitoring of these patients is advised. © 2016 Wiley Periodicals, Inc.

Basal infarct location but not larger infarct size is associated with a successful outcome after alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy: a cardiovascular magnetic resonance imaging study.

Alcohol septal ablation (ASA) is successful in most but not in all patients with obstructive hypertrophic cardiomyopathy (HCM). We therefore sought to investigate the relation between infarct location versus infarct size with outcome after ASA in patients with obstructive HCM. Baseline characteristics, procedural characteristics, and cardiovascular magnetic resonance findings at baseline and 4-6 month follow-up after ASA were analysed in 47 patients with obstructive HCM in a single-center retrospective study. Infarct size was determined using late gadolinium enhancement. Infarct location was divided into "basal infarction" and "distal infarction" based on an optimal cut-of value of the distance from the basal septum to the beginning of the infarction. A "successful" outcome was defined as 80% reduction of the invasive gradient with a post-procedural gradient of <10 mmHg. Basal infarctions (n = 31) compared to distal infarctions (n = 16) were associated with successful outcome (100 vs. 38%, P < 0.001). Larger infarct size (n = 20) compared to smaller infarct size (n = 27) was not associated with successful outcome (75 vs. 82%, P = 0.72). A more distal location of the infarction, was the only predictor of a less successful outcome (odds ratio 0.76, 95% confidence interval 0.54-0.98, P = 0.03). Basal versus distal infarctions were also associated with a lower provoked gradient at late (2.6 ± 2.2 years) follow-up (11 (6-20) vs. 27 (12-94) mmHg, P = 0.01). Basal infarctions were associated with a successful outcome after ASA. A larger infarct size was not associated with a better outcome.

Additive value of dobutamine stress echocardiography in patients with an anomalous origin of a coronary artery.

An anomalous origin of a coronary artery (AOCA) is the second most common cause of non-traumatic sudden cardiac death in young athletes. Patients with a malignant course of an AOCA of the right coronary artery only need surgical correction when myocardial ischaemia is detected. An AOCA and its malignant or benign course can be detected by coronary angiography, coronary computed tomography or cardiac magnetic resonance imaging. Detection of ischaemia can be more difficult since even a negative maximal-effort stress ECG does not exclude a potential lethal coronary anomaly. Also, there are no case series or trials showing sensitivity or specificity for any form of ischaemia detection for AOCA in the literature. Although not described previously in adults, dobutamine stress echocardiography was previously described in a paediatric population with AOCA. We are the first to describe ischaemia detection by dobutamine stress echocardiography in three adult patients with an AOCA of the right coronary artery who were subsequently referred for surgery.

Long-term outcomes after medical and invasive treatment in patients with hypertrophic cardiomyopathy.

OBJECTIVES: The aim of this study was to determine the long-term outcomes (all-cause mortality and sudden cardiac death [SCD]) after medical therapy, alcohol septal ablation (ASA), and myectomy in patients with hypertrophic cardiomyopathy (HCM). BACKGROUND: Therapy-resistant obstructive HCM can be treated both surgically and percutaneously. But there is no consensus on the long-term effects of ASA, especially on SCD. METHODS: This study included 1,047 consecutive patients with HCM (mean age 52 ± 16 years, 61% men) from 3 tertiary referral centers. A total of 690 patients (66%) had left ventricular outflow tract gradients ≥ 30 mm Hg, of whom 124 (12%) were treated medically, 316 (30%) underwent ASA, and 250 (24%) underwent myectomy. Primary endpoints were all-cause mortality and SCD. Kaplan-Meier graphs and Cox regression models were used for statistical analyses. RESULTS: The mean follow-up period was 7.6 ± 5.3 years. Ten-year survival was similar in medically treated patients (84%), ASA patients (82%), myectomy patients (85%), and patients with nonobstructive HCM (85%) (log-rank p = 0.50). The annual rate of SCD was low after invasive therapy: 1.0%/year in the ASA group and 0.8%/year in the myectomy group. Multivariate analysis demonstrated that the risk for SCD was lower after myectomy compared with the ASA group (hazard ratio: 2.1; 95% confidence interval: 1.0 to 4.4; p = 0.04) and the medical group (hazard ratio: 2.3; 95% confidence interval: 1.0 to 5.2; p = 0.04). CONCLUSIONS: Patients with obstructive HCM who are treated at referral centers for HCM care have good survival and low SCD risk, similar to that of patients with nonobstructive HCM. The SCD risk of patients after myectomy was lower than after ASA or in the medical group.

Periprocedural complications and long-term outcome after alcohol septal ablation versus surgical myectomy in hypertrophic obstructive cardiomyopathy: a single-center experience.

OBJECTIVES: This study compared alcohol septal ablation (ASA) and surgical myectomy for periprocedural complications and long-term clinical outcome in patients with symptomatic hypertrophic obstructive cardiomyopathy. BACKGROUND: Debate remains whether ASA is equally effective and safe compared with myectomy. METHODS: All procedures performed between 1981 and 2010 were evaluated for periprocedural complications and long-term clinical outcome. The primary endpoint was all-cause mortality; secondary endpoints consisted of annual cardiac mortality, New York Heart Association functional class, rehospitalization for heart failure, reintervention, cerebrovascular accident, and myocardial infarction. RESULTS: A total of 161 patients after ASA and 102 patients after myectomy were compared during a maximal follow-up period of 11 years. The periprocedural (30-day) complication frequency after ASA was lower compared with myectomy (14% vs. 27%, p = 0.006), and median duration of in-hospital stay was shorter (5 days [interquartle range (IQR): 4 to 6 days] vs. 9 days [IQR: 6 to 12 days], p < 0.001). After ASA, provoked gradients were higher compared with myectomy (19 [IQR: 10 to 42] vs. 10 [IQR: 7 to 13], p < 0.001). After multivariate analysis, age (per 5 years) (hazard ratio: 1.34 [95% confidence interval: 1.08 to 1.65], p = 0.007) was the only independent predictor for all-cause mortality. Annual cardiac mortality after ASA and myectomy was comparable (0.7% vs. 1.4%, p = 0.15). During follow-up, no significant differences were found in symptomatic status, rehospitalization for heart failure, reintervention, cerebrovascular accident, or myocardial infarction between both groups. CONCLUSIONS: Survival and clinical outcome were good and comparable after ASA and myectomy. More periprocedural complications and longer duration of hospital stay after myectomy were offset by higher gradients after ASA.