Clinical characteristics and outcomes of alcohol septal ablation in the era of transcatheter valve interventions.

BACKGROUND: The clinical efficacy and safety of alcohol septal ablation (ASA) for obstructive hypertrophic cardiomyopathy (HCM) have been well-established; however, less is known about outcomes in patients undergoing preemptive ASA before transcatheter mitral valve replacement (TMVR). AIMS: The goal of this study is to characterize the procedural characteristics and examine the clinical outcomes of ASA in both HCM and pre-TMVR. METHODS: This retrospective study compared procedural characteristics and outcomes in patient who underwent ASA for HCM and TMVR. RESULTS: In total, 137 patients were included, 86 in the HCM group and 51 in the TMVR group. The intraventricular septal thickness (mean 1.8 vs. 1.2 cm; p < 0.0001) and the pre-ASA LVOT gradient (73.6 vs. 33.8 mmHg; p ≤ 0.001) were higher in the HCM group vs the TMVR group. The mean volume of ethanol injected was higher (mean 2.4 vs. 1.7 cc; p < 0.0001). The average neo-left ventricular outflow tract area increased significantly after ASA in the patients undergoing TMVR (99.2 ± 83.37 mm2 vs. 196.5 ± 114.55 mm2; p = <0.0001). The HCM group had a greater reduction in the LVOT gradient after ASA vs the TMVR group (49.3 vs. 18 mmHg; p = 0.0040). The primary composite endpoint was higher in the TMVR group versus the HCM group (50.9% vs. 25.6%; p = 0.0404) and had a higher incidence of new permanent pacemaker (PPM) (25.5% vs. 18.6%; p = 0.3402). The TMVR group had a higher rate of all-cause mortality (9.8% vs. 1.2%; p = 0.0268). CONCLUSIONS: Preemptive ASA before TMVR was performed in patients with higher degree of clinical comorbidities, and correspondingly is associated with worse short-term clinical outcomes in comparison to ASA for HCM patients. ASA before TMVR enabled percutaneous mitral interventions in a small but significant minority of patients that would have otherwise been excluded. The degree of LVOT and neoLVOT area increase is significant and predictable.

Neoadjuvant chemotherapy and radiotherapy followed by resection/ablation in stage IV rectal cancer patients with potentially resectable metastases.

BACKGROUND: The optimal treatment of stage IV rectal cancer remains controversial. The purpose of this study was to assess the treatment outcomes and toxicity of neoadjuvant chemotherapy and radiotherapy followed by local treatment of all tumor sites and subsequent adjuvant chemotherapy in stage IV rectal cancer patients with potentially resectable metastases. METHODS: Adult patients diagnosed with locally advanced rectal adenocarcinoma with potentially resectable metastases, who received neoadjuvant chemotherapy and radiotherapy from July 2013 and September 2019 at Sun Yat-sen University cancer center, were included. Completion of the whole treatment schedule, pathological response, treatment-related toxicity and survival were evaluated. RESULTS: A total of 228 patients were analyzed with a median follow-up of 33 (range 3.3 to 93.4) months. Eventually, 112 (49.1%) patients finished the whole treatment schedule, of which complete response of all tumor sites and pathological downstaging of the rectal tumor were observed in three (2.7%) and 90 (80.4%) patients. The three-year overall survival (OS) and progression-free survival (PFS) of all patients were 56.6% (50.2 to 63.9%) and 38.6% (95% CI 32.5 to 45.8%), respectively. For patients who finished the treatment schedule, 3-year OS (74.4% vs 39.2%, P < 0.001) and 3-year PFS (45.5% vs 30.5%, P = 0.004) were significantly improved compared those who did not finish the treatment. Grade 3-4 chem-radiotherapy treatment toxicities were observed in 51 (22.4%) of all patients and surgical complications occurred in 22 (9.6%) of 142 patients who underwent surgery, respectively. CONCLUSIONS: Neoadjuvant chemotherapy and radiotherapy followed by resection/ablation and subsequent adjuvant chemotherapy offered chances of long-term survival with tolerable toxicities for selected patients with potentially resectable stage IV rectal cancer, and could be considered as an option in clinical practice.

Evidence-Based Management of Hepatocellular Carcinoma: Systematic Review and Meta-analysis of Randomized Controlled Trials (2002-2020).

BACKGROUND & AIMS: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality, with a rapidly changing landscape of treatments. In the past 20 years, numerous randomized controlled trials (RCTs) have aimed at improving outcomes across disease stages. We aimed to analyze the current evidence and identify potential factors influencing response to therapies. METHODS: We conducted a systematic review of phase III RCTs (2002-2020) across disease stages. A meta-analysis was designed to examine the relationship between etiology and outcome after systemic therapies with either tyrosine-kinase inhibitor (TKI)/antiangiogenic or immune checkpoint inhibitor (ICI) therapy. RESULTS: Out of 10,100 studies identified, 76 were phase III RCTs. Among them, a rigorous screening algorithm identified 49 with high quality including a total of 22,113 patients undergoing adjuvant (n = 7) and primary treatment for early (n = 2), intermediate (n = 7), and advanced (first-line, n = 21; second-line, n = 12) stages of disease. Nine of these trials were positive, 6 treatments have been adopted in guidelines (sorafenib [2 RCTs], lenvatinib, atezolizumab+bevacizumab, regorafenib, cabozantinib and ramucirumab), but 2 were not (adjuvant CIK cells and sorafenib plus hepatic arterial infusion with FOLFOX). Meta-analysis of 8 trials including 3739 patients revealed ICI therapy to be significantly more effective in patients with viral hepatitis compared with nonviral-related HCC, whereas no differences related to etiology were observed in patients treated with TKI/anti-vascular endothelial growth factor. CONCLUSIONS: Among 49 high-quality RCTs conducted in HCC during 2002-2020, 9 resulted in positive results. A meta-analysis of systemic therapies suggests that immunotherapies may be more effective in viral etiologies.

Image-Guided Percutaneous Ablation of Adrenal Metastases: A Meta-Analysis of Efficacy and Safety.

PURPOSE: To evaluate the efficacy and safety of percutaneous ablation of adrenal metastases through a meta-analysis of various image-guided percutaneous ablation techniques. MATERIALS AND METHODS: A comprehensive literature search of PubMed and Embase databases was performed for studies evaluating the efficacy and/or safety of image-guided percutaneous ablation of adrenal metastases. A total of 37 studies published between 2009 and 2020 were analyzed, comprising a sample size of 959 patients. Proportion estimates of overall survival, local control, and toxicity were analyzed in a pooled meta-analysis. The pooled prevalence of adverse events after ablation was calculated based on common terminology criteria for adverse events (CTCAE) grading. RESULTS: Of the 959 included patients, 320 (33.3%) underwent radiofrequency ablation, 72 (7.5%) microwave ablation, 95 (9.9%) cryoablation, and 46 (4.8%) ethanol injections for treatment of adrenal metastases. The remaining 426 (44.4%) patients were from studies involving a mixture of the 4 listed percutaneous ablation techniques. The pooled 1-year local control rate was 80% (95% confidence interval [CI], 76%-83%). The pooled 1-year overall survival rate was 77% (95% CI, 70%-83%). The overall rate of severe adverse events after ablation (CTCAE grade 3 or higher) was 16.1%. The overall rate of low-grade adverse events after ablation (CTCAE grade 2 or lower) was 32.6%. Approximately 21.9% (n = 203) of patients experienced intraprocedural hypertensive crises, the majority of which were reversed with antihypertensive medications. CONCLUSIONS: This study demonstrates that image-guided percutaneous ablation can be effective in achieving acceptable short- to mid-term local tumor control and overall survival with a moderate safety profile.

Image-Guided Percutaneous Thermal Ablation of Oligometastatic Ovarian and Non-Ovarian Gynecologic Tumors.

PURPOSE: To assess the safety, feasibility, and efficacy of percutaneous thermal ablation (TA) in the treatment of metastatic gynecologic (GYN) tumors. MATERIALS AND METHODS: A study cohort of 42 consecutive women (mean age, 59. years; range, 25-78 years) with metastatic GYN tumors (119 metastatic tumors) treated with radiofrequency (n = 47 tumors), microwave (n = 47 tumors), or cryogenic (n = 30 tumors) ablation from over 2,800 ablations performed from January 2001 to January 2019 was identified. The primary GYN neoplasms consisted of ovarian (27 patients; 77 tumors; mean tumor diameter [MTD], 2.50 cm), uterine (7 patients; 26 tumors; MTD, 1.89 cm), endometrial (5 patients; 10 tumors; MTD, 2.8 cm), vaginal (2 patients; 5 tumors; MTD, 2.40 cm), and cervical (1 patient; 1 tumor; MTD, 1.90 cm) cancers. In order of descending frequency, metastatic tumors treated by TA were located in the liver or liver capsule (74%), lungs (13%), and peritoneal implants (9%). Single tumors were also treated in the kidneys, rectus muscle, perirectal soft tissue (2.5%), and retroperitoneal lymph nodes (1.6%). All efficacy parameters of TA and definitions of major and minor adverse events are categorized by the latest Society of Interventional Radiology reporting standards. RESULTS: The median follow-up of treated patients was 10 months. After the initial ablation, 95.6% of the patients achieved a complete tumor response confirmed by contrast-enhanced magnetic resonance imaging or computed tomography. On surveillance imaging, 8.5% of the ablated tumors developed local progression over a median follow-up period of 4.1 months. Five of 8 tumors with local recurrence underwent repeated treatment over a mean follow-up period of 18 months, and 4 of 5 tumors achieved complete eradication after 1 additional treatment session that resulted in a secondary efficacy of 80%. The overall technique efficacy of TA was 96.2% over a median follow-up period of 10 months. CONCLUSIONS: TA was safe and effective for the local control of metastatic GYN tumors in the lungs, abdomen, and pelvis, with an overall survival rate of 37.5 months and a local progression-free survival rate of 16.5 months, with only 4.8% of treated patients experiencing a major adverse event.

Trends of hospital-based surgery for varicose veins in the elderly.

OBJECTIVE: The treatment of varicose veins has shifted during the past decade to the office setting. Although recent studies have demonstrated the safety of venous ablation for the elderly in the office, a paucity of data is available on the contemporary outcomes of surgery for varicose veins in the operating room. The present study analyzed the trends and outcomes of varicose vein surgery in the elderly using a large national database. METHODS: The American College of Surgeons National Surgical Quality Initiative Program database (2005-2017) was reviewed. Patients undergoing vein ablation or open surgery (ie, high ligation, stripping, phlebectomy) for venous insufficiency were identified using Current Procedural Terminology codes and the principal diagnosis. The patients were stratified into 3 age groups <65, 65 to 79, and ≥80 years. The preoperative and operative characteristics and outcomes were compared. Logistic regression was performed to identify the risk factors associated with any adverse event, defined as any morbidity or mortality. RESULTS: A total of 48,615 venous surgeries had been performed, with 9177 (18.9%) performed in patients aged 65 to 79 years and 1180 (2.4%) in patients aged ≥80 years. The proportion of patients in the 65- to 79-age group had steadily increased during the study period from 12.8% in 2005 to 22.3% in 2017 (P < .01). The proportion of patients aged ≥80 years had remained stable (P = .23). Patients aged ≥80 years had significantly more comorbidities, were more likely to have undergone vein ablation alone (P < .01), were more likely to be treated for ulceration (P < .01) and less likely to have received general anesthesia (P < .01) compared with the younger age groups. Overall morbidity increased significantly with increased age group (P < .01) but remained low (2.5%). Mortality was very low (0.02%) and not significantly different among the age groups. The factors independently associated with any adverse event were dialysis (odds ratio [OR], 7.12; 95% confidence interval [CI], 3.3-15.6), American Society of Anesthesiologists classification per unit increase (OR, 1.2; 95% CI, 1.02-1.3), use of general anesthesia (OR, 1.2; 95% CI, 1.0-1.4), and combined venous ablation and open procedures compared with venous ablation alone (OR, 1.3; 95% CI, 1.0-1.5). However, age was not associated with adverse events (OR, 1.0; 95% CI, 1.0-1.0). CONCLUSIONS: Varicose vein surgery is safe for all age groups and is being increasingly offered to the elderly. High-risk patients might benefit from the avoidance of hybrid procedures and general anesthesia when possible to minimize the occurrence of adverse events. Conservative measures should be exhausted before surgery for the dialysis population.

Management of atrial fibrillation after transcatheter aortic valve replacement: Challenges and therapeutic considerations.

Atrial Fibrillation (AF) is very common among patients with severe aortic stenosis. Moreover, new onset AF (NOAF) is a frequent finding after Transcatheter Aortic Valve Replacement (TAVR). There is a significant impact of AF on outcomes in patients undergoing TAVR including mortality, thrombo-embolic and bleeding events. There is lack of clear evidence about the optimal management of AF in TAVR patients. This review aims to summarize the epidemiology, predictors, prognosis, therapeutic considerations and challenges in the management of AF in patients undergoing TAVR.

Transcatheter CT Hepatic Arteriography Compared with Conventional CT Fluoroscopy Guidance in Percutaneous Thermal Ablation to Treat Colorectal Liver Metastases: A Single-Center Comparative Analysis of 2 Historical Cohorts.

PURPOSE: To evaluate safety and efficacy of CT hepatic arteriography compared with conventional CT fluoroscopy guidance in percutaneous radiofrequency (RF) and microwave (MW) ablation to treat colorectal liver metastases (CRLM). MATERIALS AND METHODS: This single-center comparative, retrospective study analyzed data of 108 patients treated with 156 percutaneous ablation procedures (42 CT fluoroscopy guidance [25 RF ablation, 17 MW ablation]; 114 CT hepatic arteriography guidance [18 RF ablation, 96 MW ablation]) for 260 CRLM between January 2009 and May 2019. Local tumor progression-free survival (LTPFS) was assessed using univariate and multivariate Cox proportional hazard regression analyses. LTPFS and overall survival (OS) were estimated using the Kaplan-Meier method. RESULTS: There were no complications related to the transarterial catheter procedure. CT hepatic arteriography proved superior to CT fluoroscopy regarding 2-year LTPFS (18/202 [8.9%] vs 19/58 [32.8%]; P < .001, respectively). CT hepatic arteriography versus CT fluoroscopy (hazard ratio = 0.28; 95% confidence interval, 0.15-0.54; P < .001) and MW ablation versus RF ablation (hazard ratio = 0.52; 95% confidence interval, 0.24-1.12; P = .094) were positive predictors for longer LTPFS. Multivariate analysis revealed that CT hepatic arteriography versus CT fluoroscopy (hazard ratio = 0.41; 95% confidence interval, 0.19-0.90; P = .025) was associated with a significantly superior LTPFS. OS was similar between the 2 cohorts (P = .3). CONCLUSIONS: While adding procedure time and marginal patient burden, transcatheter CT hepatic arteriography-guided ablation was associated with increased local disease control and superior LTPFS compared with conventional CT fluoroscopy. CT hepatic arteriography represents a safe and valid alternative to CT fluoroscopy, as it reduces the number of repeat ablations required without adding risk or detrimental effect on survival.

Value of CT-Guided Percutaneous Irreversible Electroporation Added to FOLFIRINOX Chemotherapy in Locally Advanced Pancreatic Cancer: A Post Hoc Comparison.

PURPOSE: To compare survival after CT-guided percutaneous irreversible electroporation (IRE) and folinic acid, fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX) chemotherapy versus FOLFIRINOX only in patients with locally advanced pancreatic cancer (LAPC). MATERIALS AND METHODS: A post hoc comparison was performed of data derived from a prospective IRE-FOLFIRINOX cohort and a retrospective FOLFIRINOX-only cohort. All patients received a minimum of 3 cycles of FOLFIRINOX for LAPC and were considered eligible for CT-guided percutaneous IRE. Endpoints included overall survival (OS), local and distant progression-free survival, and time to progression (TTP) and were compared using stratified Kaplan-Meier analysis. Patients who received > 8 cycles of FOLFIRINOX before IRE and who had tumors > 6 cm in the FOLFIRINOX-only group were excluded. RESULTS: Of 103 patients with a diagnosis of LAPC, 52 were deemed eligible (n = 30 IRE-FOLFIRINOX and n = 22 FOLFIRINOX-only). Patients in the FOLFIRINOX-only arm had larger tumors (53 mm ± 19 vs 38 mm ± 7, P = .340), had more locoregional lymph node metastases (23% vs 7%, P = .622), and more often received radiotherapy (7 patients vs 2 patients, P = .027); all other baseline characteristics were comparable. Median OS was 17.0 months (range, 5-35 mo; SD = 6) for IRE-FOLFIRINOX versus 12.4 months (range, 3-22 mo; SD = 6) for FOLFIRINOX-only (P = .038). After sensitivity analyses, median OS was 17.2 months (range, 6-27 mo; SD = 6) versus 12.4 months (range, 7-32 mo; SD = 10) (P = .05). Median TTP was longer in the IRE-FOLFIRINOX group: 14.2 months (range, 5-25 mo; SD = 4) versus 5.2 months (range, 2-22; SD = 6) (P = .0001). CONCLUSIONS: In patients with LAPC after FOLFIRINOX chemotherapy, CT-guided percutaneous IRE may improve OS and TTP. This study may facilitate the design of randomized controlled trials to compare survival after IRE-FOLRINOX versus FOLFIRINOX-only.

Percutaneous Microwave Ablation versus Laparoscopic Partial Nephrectomy for cT1a Renal Cell Carcinoma: A Propensity-matched Cohort Study of 1955 Patients.

Background Percutaneous microwave ablation (MWA) and laparoscopic partial nephrectomy (LPN) are two modalities indicated for early-stage renal cell carcinoma (RCC) with low extent of invasion. Purpose To compare the long-term results of percutaneous MWA and LPN in the treatment of cT1a RCC. Materials and Methods This retrospective study included 1955 patients with cT1a RCC treated with percutaneous MWA or LPN between April 2006 and November 2017. Propensity score matching was used. Oncologic outcomes were analyzed by using the Fine-and-Gray competing risk models. Results A total of 185 patients underwent percutaneous MWA (mean age, 63.2 years ± 15.2 [standard deviation]) and 1770 underwent LPN (mean age, 50.9 years ± 13.2). During the follow-up (median, 40.6 months), after propensity score matching, no difference was observed between local tumor progression (3.2% vs 0.5%, P = .10), cancer-specific survival (2.2% vs 3.8%, P = .24), and distant metastases (4.3% vs 4.3%, P = .76). Patients who underwent percutaneous MWA had worse overall survival (hazard ratio, 2.4; 95% confidence interval: 1.0, 5.7; P = .049 vs LPN) and disease-free survival (82.9% vs 91.4%, P = .003). Percutaneous MWA led to smaller drop in estimated glomerular filtration rate at discharge (6.2% vs 16.4%, P < .001), smaller estimated blood loss (4.5 mL ± 1.3 vs 54.2 mL ± 69.2), lower cost ($3150 ± 2970 vs $6045 ± 1860 U.S. dollars), shorter operative time (0.5 minute ± 0.1 vs 1.8 minutes ± 0.6), and shorter postoperative hospitalization time (5.1 days ± 2.6 vs 6.9 days ± 2.8) (all P < .001 vs LPN). There were fewer cases of fever in the percutaneous MWA group (16.2% vs 73.0%, P < .001). Conclusion There were no significant differences regarding oncologic outcomes and complications between percutaneous microwave ablation and laparoscopic partial nephrectomy for patients with cT1a renal cell carcinoma. Percutaneous microwave ablation led to smaller renal function change and lower blood loss. For patients who cannot be subjected to the risks of more invasive laparoscopic partial nephrectomy, percutaneous microwave ablation could be an alternative less invasive treatment option. © RSNA, 2020 Online supplemental material is available for this article.

Outcomes of hypertrophic obstructive cardiomyopathy patients undergoing alcohol septal ablation with a standard 3 mL dose of ethanol: Focus on long-term safety.

OBJECTIVES: The objective of this research was to assess the long-term results of alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy (HOCM), with all of them receiving a standard 3 mL ethanol dose. BACKGROUND: Generally, ethanol (0.5-3 mL) is infused depending on a septal artery width or interventricular septum (IVS) thickness during alcohol septal ablation. We injected 3 mL of ethanol irrespective of IVS thickness or perforator width in all cases. METHODS: Between 2000 and 2017, 150 HOCM patients (78 males, 72 females) underwent alcohol septal ablation procedures. In all cases we intentionally used the constant dose of ethanol (3 mL). The median of age was 52 (interquartile range: 41-60) years. RESULTS: The median of follow-up was 71 (interquartile range: 36-110) months. Hospital mortality was 0.67% (one patient died of sepsis). Perioperative high-grade atrioventricular blocks required permanent pacemaker implantations-18 (12%). Long-term survival rates were as follows: 95.1% (95% confidence interval [CI]: 92.7-97.5%), 85.8% (95% CI: 83.7-87.0%), and 81.7% (95% CI: 79.7-83.7%) at 5-, 10-, and 15-year follow-up, respectively. One-sample log-rank test revealed no significant differences in 15-year survival rates between the alcohol septal ablation cohort and age- and sex-matched Russian population. CONCLUSIONS: Alcohol septal ablation with the standard (3 mL) ethanol dose is safe and efficient. Survival rates after alcohol septal ablation are comparable with those in age- and sex-matched general Russian population.

Stroke and thromboembolism prevention in atrial fibrillation.

Prevention of stroke and systemic thromboembolism remains the cornerstone for management of atrial fibrillation (AF) and flutter. Multiple risk assessment models for stroke and systemic thromboembolism are currently available. The score, with its known limitations, remains as the recommended risk stratification tool in most major guidelines. Once at-risk patients are identified, vitamin K antagonists (VKAs) and, more recently, direct oral anticoagulants (DOACs) are the primary medical therapy for stroke prevention. In those with contraindication for long-term anticoagulation, left atrial appendage occluding devices are developing as a possible alternative therapy. Some controversy exists regarding anticoagulation management for cardioversion of acute AF (<48 hours); however, systemic anticoagulation precardioversion and postcardioversion is recommended for those with longer duration of AF. Anticoagulation management peri-AF ablation is also evolving. Uninterrupted VKA and DOAC therapy has been shown to reduce perioperative thromboembolic risk with no significant escalation in major bleeding. Currently, under investigation is a minimally interrupted approach to anticoagulation with DOACs periablation. Questions remain, especially regarding the delivery of anticoagulation care and integration of wearable rhythm monitors in AF management.

Factors affecting survival in patients with isolated liver-metastatic colorectal cancer treated with local ablative or surgical treatments for liver metastasis.

PURPOSE: Local treatments for isolated synchronous or metachronous liver metastases in colorectal cancer (CRC) have been shown to improve overall survival (OS). The aim of this study was to investigate the factors affecting OS in CRC patients with isolated liver metastasis in whom the primary tumor and corresponding liver metastasis were treated with curative intent using local ablative or surgical methods. METHODS: A total 47 surgical operated CRC patients presenting with an initial or subsequent isolated liver metastasis, who were treated with local surgical or ablative treatment for liver metastasis with curative intent, were enrolled in this study between 2007 and 2017. The possible factors affecting OS were analyzed. RESULTS: Of the 47 patients, 35 (74.5%) were male. The median age was 61 (25 - 80) years. Thirty-four (72.3%) patients underwent liver metastasectomy, while 13 (27.7%) patients were treated with non-surgical local ablative therapies (NSLAT) for liver metastasis. Median OS (mOS) could not be reached in patients who underwent metastasectomy at the time of diagnosis compared to 55 months in those undergoing metastasectomy following a chemotherapy period (p = 0.03). Patients treated with NSLAT had a mOS of 60 months compared to ''not reached'' in those who underwent liver metastasectomy (p = 0.45). mOS was higher in patients with pT4 stage vs. with

Updates and advancements in the management of hepatocellular carcinoma patients after hepatectomy.

Introduction: The 5-year recurrence rate of hepatocellular carcinoma (HCC) after hepatic resection or local ablation is up to 70%. Adjuvant therapies to prevent HCC recurrence have been reported but are not currently recommended by EASL or AASLD guidelines. This review examined evidence from randomized controlled trials, meta-analyses and systematic reviews on the safety and efficacy of adjuvant therapies and chemotherapies in HCC patients after resection or local ablation.Areas covered: PubMed was searched through 15 June 2019. Available evidence was assessed based on the GRADE system.Expert commentary: Transarterial chemoembolization is the best adjuvant therapy for HCC patients at high risk of recurrence, antiviral therapy with nucleoside analogs is effective for preventing recurrence of HBV-related HCC, and interferon-α is effective for preventing recurrence of HCV-related HCC. Further studies are needed to clarify the efficacy of adjuvant immune checkpoint inhibitors. Adjuvant sorafenib appears to offer negligible clinical benefit and high risk of adverse effects.

Guideline-Based Referral for Septal Reduction Therapy in Obstructive Hypertrophic Cardiomyopathy Is Associated With Excellent Clinical Outcomes.

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.

A Comparison of Cryoablation with Heat-Based Thermal Ablation for Treatment of Clinical T1a Renal Cell Carcinoma: A National Cancer Database Study.

PURPOSE: To compare the overall survival (OS) of patients receiving cryoablation versus heat-based thermal ablation for clinical T1a renal cell carcinoma (RCC) in a large national cohort. MATERIALS AND METHODS: Patients with RCC from 2004 to 2014 who were treated with ablation were identified from the National Cancer Database. OS was estimated with the use of the Kaplan-Meier method and evaluated by means of log-rank test, univariate and multivariate Cox proportional hazard regression, and propensity score-matched analysis. RESULTS: A total of 3,936 patients who received cryoablation and 2,322 who received heat-based thermal ablation met the inclusion criteria. The mean age was 67 ± 12 year, and the mean size of tumors was 25 ± 8 mm. The 3-, 5-, and 10-year survival rates were, respectively, 91%, 82%, and 62% for cryoablation and 89%, 81%, and 55% for heat-based thermal ablation. After propensity score matching, cryoablation was associated with longer OS compared with heat-based thermal ablation (median 11.3 vs 10.4 years; hazard ratio 1.175, 95% CI 1.03-1.341; P = .016). For patients with tumors ≤2 cm, propensity score-matched analyses demonstrated no significant difference between the 2 treatment groups (P = .772). CONCLUSIONS: Overall, cryoablation may be associated with longer OS compared with heat-based thermal ablation in cT1a RCC. No significant difference in survival rates was observed between the 2 treatments for patients with tumor sizes ≤2 cm. Owing to the inherent limitations of this study, further study with details on technology, local outcome, and complications is needed.

Thermal ablation versus wedge or segmental resection in patients with early stage hepatocellular carcinoma: a population survival analysis.

BACKGROUND: The aim of this retrospective review was to evaluate the long-term survival benefits of thermal ablation versus wedge or segmental resection in solitary HCC lesions using tumor size and clinical factors. METHODS: Survival analysis was performed on 43,601 patients from 2004 to 2015 in the National Cancer Database with solitary HCC lesions ≤5 cm with further stratification by tumor size, fibrosis score, and type of resection. RESULTS: In patients with moderate fibrosis or less, survival benefit was seen with one-segment resection over ablation in tumors 1.1-3 cm (HR 0.54, p = 0.03) while tumors of 3.1-5 cm received survival benefit from wedge (HR 0.44, p = 0.04), one (HR 0.28, p = 0.001) and two-segment (HR 0.20, p = 0.001) resections over ablation. In patients with severe fibrosis to cirrhosis, wedge resection demonstrated survival benefit over ablation in patients with tumors 1.1-3 cm (HR 0.48, p = 0.01) with no survival benefit of any resection type in patients with tumors of 3.1-5 cm. CONCLUSION: These findings suggest that the decision to utilize thermal ablation versus resection to extend survival in solitary HCC lesions should include tumor size, fibrosis score, and type of resection.

Long-term outcome of conservative and invasive treatment in patients with hypertrophic obstructive cardiomyopathy.

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.