Survival After Septal Reduction in Patients >65 Years Old With Obstructive Hypertrophic Cardiomyopathy.

BACKGROUND: Obstructive hypertrophic cardiomyopathy (oHCM) is increasingly being diagnosed in elderly patients. OBJECTIVES: The authors sought to study long-term outcomes of septal reduction therapies (SRT) in Medicare patients with oHCM, and hospital volume-outcome relation. METHODS: Medicare beneficiaries aged >65 years who underwent SRT, septal myectomy (SM) or alcohol septal ablation (ASA), from 2013 through 2019 were identified. Primary outcome was all-cause mortality, and secondary outcomes included heart failure (HF) readmission and need for redo SRT in follow-up. Overlap propensity score weighting was used to adjust for differences between both groups. Relation between hospital SRT volume and short-term and long-term mortality was studied. RESULTS: The study included 5,679 oHCM patients (SM = 3,680 and ASA = 1,999, mean age 72.9 vs 74.8 years, women 67.2% vs 71.1%; P < 0.01). SM patients had fewer comorbidities, but after adjustment, both groups were well balanced. At 4 years (IQR: 2-6 years), although there was no difference in long-term mortality between SM and ASA (HR: 0.87; 95% CI: 0.74-1.03; P = 0.1), on landmark analysis, SM was associated with lower mortality after 2 years of follow-up (HR: 0.72; 95% CI: 0.60-0.87; P < 0.001) and had lower need for redo SRT. Both reduced HF readmissions in follow-up vs 1 year pre-SRT. Higher-volume centers had better outcomes vs lower-volume centers, but 70% of SRT were performed in low-volume centers. CONCLUSIONS: SRT reduced HF readmission in Medicare patients with oHCM. SM is associated with lower redo and better long-term survival compared with ASA. Despite better outcomes in high-volume centers, 70% of SRT are performed in low-volume U.S. centers.

Septal Ablation and Hypertrophic Obstructive Cardiomyopathy: 7 Years US Experience.

BACKGROUND: Septal ablation (SA) is a key modality for left ventricular outflow tract gradient reduction in hypertrophic obstructive cardiomyopathy (HOCM) patients with refractory symptoms. The primary objective of our study was to evaluate post-procedural mortality, complications, length of stay (LOS), and cost of hospitalization following SA. METHODS: We queried the Nationwide Inpatient Sample (NIS) between 2005 and 2011 using the ICD9 procedure code of 37.34 for ablation of heart tissue. Only adult patients with HOCM (ICD-9-CM: 425.1) were included. Patients with any arrhythmia diagnosis or open surgical ablation procedure code were excluded. Hierarchical mixed effects models were generated in order to identify the independent multivariate predictors of outcomes. RESULTS: A total of 358 SAs were available for analysis. There was no reported mortality during the study period; permanent pacemaker implantation rate was 8.7%. Highest hospital volume tertile (OR, 95%CI, P- value) predicted significantly lower post-procedural complications (0.51, 0.26-0.98, P = 0.04). Univariate analysis of highest versus lowest tertile of hospital volume showed significant decrease in LOS (2.6 days vs. 3.8 days, P<0.01) and non-significant decrease hospitalization costs (16,800$ vs. 19,500$, P = 0.29). CONCLUSIONS: SA is a safe procedure and associated with low peri- procedural mortality rate. A higher burden of baseline comorbidities is associated with worse outcomes while higher annual hospital volume is associated with lower rate of post-procedural complications, length of stay, and cost of care following SA.

Contrast-enhanced Steady-state Free Precession in the Assessment of Hypertrophic Obstructive Cardiomyopathy after Alcohol Septal Ablation.

PURPOSE: We evaluated the feasibility of contrast-enhanced steady-state free precession (ceSSFP) in the assessment of myocardial injury and obstruction of the left ventricular outflow tract (LVOT) in patients with hypertrophic obstructive cardiomyopathy (HOCM) after alcohol septal ablation (ASA). METHODS: Twelve patients with HOCM underwent 16 magnetic resonance (MR) examinations following ASA. Precontrast SSFP, ceSSFP and late gadolinium enhancement (LGE) imaging were performed with a 1.5-tesla imager. ceSSFP was performed 3 to 7 min after gadolinium injection. We visually and quantitatively evaluated the signal patterns of the myocardium after ASA on SSFP and LGE MR imaging. We observed the LVOT using ceSSFP in the 3-chamber view. RESULTS: We could visualize ASA-induced myocardial infarction (MI) in all 16 studies by LGE and ceSSFP but in only 6 studies (37.5%) by precontrast SSFP. Contrast was higher between MI and remote myocardium with LGE than ceSSFP (P < 0.01). ASA-induced hypointense regions were well visualized by the 2 sequences after contrast in the 7 patients who underwent MR imaging within 7 weeks of ASA and in a few patients after 80 weeks from ASA. The ceSSFP allowed comparable visualization of the jet flow crossing the LVOT to that derived from echocardiographic data. CONCLUSION: Contrast-enhanced steady-state free precession allows assessment of myocardial injury as well as of the left ventricular outflow tract after alcohol septal ablation in a single scan without penalty in scan time and cine imaging contrast.

Live/real time three-dimensional transesophageal echocardiographic assessment of ventricular septal volume and mass before and after myectomy in hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is the most common genetically transmitted cardiomyopathy. In patients resistant to medical management, myectomy is the surgical procedure of choice to reduce the symptoms of left ventricular outflow obstruction. Two-dimensional transesophageal echocardiography (2DTEE) has become part of the operative procedure by decreasing the incidence of postoperative complications. However, because of the three-dimensional geometry of left ventricular outflow tract, it is unable to comprehensively assess the location and severity of the obstruction and to provide accurate guidance during myectomy. In this study, 10 patients with HCM underwent live/real time three-dimensional transesophageal echocardiography (3DTEE) intra-operatively to measure the volume of the resected septum. This volume correlated well with the volume of the resected septal muscle directly obtained using a graduating cylinder containing water (r = 0.9, P < 0.000). 3DTEE may be potentially used as an adjunct to guide the surgeon in performing an adequate myectomy with a lower incidence of residual obstruction and complications such as an iatrogenic ventricular septal defect.

Is multidetector computed tomography a suitable alternative to MR imaging for the assessment of myocardial necrosis after alcohol septal ablation?

BACKGROUND: To compare magnetic resonance (MR) imaging and multidetector computed tomography (MDCT) for the assessment of myocardial infarction (MI) after alcohol septal ablation (ASA). METHODS: Ten patients (mean age, 60 years ± 16) were examined with both MDCT and 1.5-T MR imaging performed 10 minutes after injection, within 3 days after ASA. Half of them had a temporary pacemaker (PM) during MDCT examination. Global image quality (IQ) and localization of MI were noticed on both MDCT and MR images. Volumes of MI, contrast-to-noise ratios (CNR) and signal-to-noise ratios (SNR) were also calculated. ASA effectiveness was evaluated by echocardiography immediately and 3 months after procedure. RESULTS: Global IQ was considered adequate for both procedures. In 8 patients, MI reached the basal part of the septum on both MDCT and MR images. The 2 remaining patients exhibited sparing of the basal septum on MDCT and MR images. Volumes of MI were within the same range with the 2 techniques (MDCT: 22.1 ± 8.8 mL; MR imaging: 23.8 ± 9.4 mL) and correlated well each other (R(2)=0.85, p<0.002). The 2 patients with sparing of the basal interventricular septum had persistent gradient on echocardiography 3 months after ASA, suggesting failure of the procedure. The volumes of MI didn't correlate with the reduction of pressure gradient on echocardiography 3 months after ASA (R(2)=0.02, p<0.05). CONCLUSIONS: Evaluation of post ASA MI is feasible with MDCT by comparison with MR imaging. MDCT might serve as an alternative imaging method in case of PM implantation.

Assessment of atrial septal defect morphology by transthoracic three dimensional echocardiography using standard grey scale and Doppler myocardial imaging techniques: comparison with magnetic resonance imaging and intraoperative findings.

OBJECTIVE: To determine whether transthoracic three dimensional echocardiography is an accurate non-invasive technique for defining the morphology of atrial septal defects (ASD). METHODS: In 34 patients with secundum ASD, mean (SD) age 20 (17) years (14 male, 20 female), the measurements obtained from three dimensional echocardiography were compared to those obtained from magnetic resonance imaging (MRI) or surgery. Three dimensional images were constructed to simulate the ASD view as seen by a surgeon. Measured variables were: maximum and minimum vertical and horizontal ASD dimension, and distances to inferior and superior vena cava, coronary sinus, and tricuspid valve. In each patient two ultrasound techniques were used to acquire three dimensional data: standard grey scale imaging (GSI) and Doppler myocardial imaging (DMI). RESULTS: Good correlation was found in maximum ASD dimension (both horizontal and vertical) between three dimensional echocardiography and both MRI (GSI r = 0.96, SEE = 0.05 cm; DMI r = 0.97, SEE = 0.04 cm) and surgery (GSI r = 0.92, SEE = 0.06 cm; DMI r = 0.95, SEE = 0.06 cm). The systematic error was similar for both three dimensional techniques when compared to both MRI (GSI = 0.40 cm (27%); DMI = 0.38 cm (25%)) and surgery (GSI = 0.50 cm (29%); DMI = 0.37 cm (22%)). A significant difference was found in both horizontal and vertical ASD dimension changes during the cardiac cycle. This change was inversely correlated with age. These findings were consistent for both DMI and GSI technique. In children (age < or = 17 years), the feasibility of detecting structures and undertaking measurements was similar for both echo techniques. However, in adult ASD patients (age > or = 18 years) this feasibility was higher for DMI than for GSI. CONCLUSIONS: Transthoracic three dimensional imaging using both GSI and DMI accurately displayed the varying morphology, dimensions, and spatial relations of ASD. However, DMI was a more effective technique than GSI in describing ASD morphology in adults.

Assessment of left ventricular outflow in hypertrophic cardiomyopathy using anyplane and paraplane analysis of three-dimensional echocardiography.

This study analyzes the alterations in size and geometry of the left ventricular (LV) outflow tract that occur in hypertrophic cardiomyopathy (HC) using transthoracic 3-dimensional echocardiography. Transthoracic 3-dimensional echocardiography was performed in 17 patients with HC (4 after myectomy) and in 10 normal subjects. Images were acquired with the rotational approach, with electrocardiographic and respiratory gating. From the 3-dimensional datasets, short-axis parallel slicing of the LV outflow tract at a 1mm distance was performed at the onset of systole. For each slice, cross-sectional area and maximal and minimal diameter were calculated. Reconstruction of the LV outflow tract could be displayed in 3 dimensions in all patients, allowing orientation and clear definition of the irregular geometry. In patients with HC, the minimal LV outflow tract cross-sectional area was smaller than in normal subjects (2.3 +/- 1.0 vs 5.0 +/- 0.9 cm(2), p < 0.0001). The ratio between maximal and minimal cross-sectional areas was higher in patients with HC than in normal subjects (2.6 +/- 0.9 vs 1.4 +/- 0.2, p <0.0001). The ratio between maximal and minimal diameter of the smallest cross section of the LV outflow tract was also significantly higher in patients with HC than in normal subjects (1.6 +/- 0.3 vs, 1.2 +/- 0. 1, p <0.001); a value of 1.36 separated normal subjects from HC patients without previous myectomy. In conclusion, precordial 3-dimensional echocardiography allows detailed qualitative and quantitative information on the LV outflow tract. Patients with HC are characterized by a highly eccentric and asymmetric shape of the LV outflow tract, and by a smaller minimal cross-sectional area than that seen in normal subjects.

Morphologic determinants of hemodynamic state after ventricular septal myotomy-myectomy in patients with obstructive hypertrophic cardiomyopathy: M mode and two-dimensional echocardiographic assessment.

To define the morphologic features of the left ventricle after ventricular septal myotomy-myectomy and to elucidate the structural changes associated with a postoperative reduction in the pressure gradient, 28 patients with obstructive hypertrophic cardiomyopathy were studied with M mode and qualitative and quantitative two-dimensional echocardiography. Nine patients with a marked reduction in the pressure gradient (no or small, less than or equal to 25 mm Hg, residual basal gradient) demonstrated a marked reduction in septal thickness after surgery (23 +/- 6 to 13 +/- 4 mm; p less than .01), a concomitant increase in septal to mitral valve distance (20 +/- 2 to 30 +/- 5 mm; p less than .005), and a loss or substantial decrease in the magnitude of systolic anterior motion of the mitral valve. Two-dimensional echocardiographic results demonstrated an increase of over 100% in the cross-sectional area of the left ventricular outflow tract at onset of systole (2.2 +/- 0.6 to 5.5 +/- 3 cm2; p less than .01). In six of the patients postoperative paradoxic septal motion appeared to contribute importantly to the increased size of the outflow tract during ventricular systole. In contrast, nine patients with little or no change in the pressure gradient (residual basal gradient greater than or equal to 40 mm Hg) demonstrated a less marked decrease in septal thickness and no significant change in septal to mitral valve distance or magnitude of mitral systolic anterior motion. Furthermore, the postoperative left ventricular outflow tract area was significantly smaller in patients with residual basal gradients (3.0 +/- 1 cm2) than that in patients with no residual gradient (5.5 +/- 3 cm2; p less than .05). Ten patients with only provocable subaortic gradients after operation showed postoperative left ventricular outflow tract dimensions intermediate between those in patients with either residual basal gradient or no residual gradient. On the basis of this echocardiographic assessment of septal myotomy-myectomy, we conclude that abolition or reduction of the subaortic gradient after operation in patients with obstructive hypertrophic cardiomyopathy is largely the consequence of surgical enlargement of the left ventricular outflow tract area.

[Echocardiographic assessment of anatomical detail in patients with hypoplastic left heart syndrome].

Hypoplastic left heart syndrome is a disease with poor prognosis, which is characterized by severe heart failure in early neonatal period. However, there are some patients who survive for relatively longer period. In the light of this fact, 18 patients with this syndrome were studied by echocardiography, and the anatomical and functional classification was attempted. Hypoplastic left heart syndrome was classified into three types: type I was mitral atresia and aortic atresia, type II was mitral atresia and aortic stenosis, and type III was mitral atresia with an abnormality of cono-truncal relationship, respectively. M-mode echocardiography was performed in 15 of the 18 patients, and two-dimensional echocardiograms were recorded in seven cases. Heart catheterization was performed in all patients. Autopsy was performed on 14 of the 18 patients, and its findings were compared with the findings obtained by echocardiography. Two-dimensional echocardiographic classification of this syndrome was possible in all the patients using above-mentioned criteria. Patent ductus arteriosus was detected in two of six cases having this syndrome, and foramen ovale in 4 of 5 cases. The morphological evaluation of both the interatrial and interventricular septum was made by two-dimensional echocardiography, and it contributed to decide the indication of balloon-atrial septostomy. The patients with type I had the poorest prognosis, and the patients with type III survived longer period. Anatomical classification of this syndrome and detection of associated anomalies by two-dimensional echocardiography are recommended to consider the prognostic and surgical considerations.