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.

Optimizing transseptal puncture guided by three-dimensional mapping: the role of a unipolar electrogram in a needle tip.

AIMS: A three-dimensional electroanatomic mapping system-guided transseptal puncture (3D-TSP), without fluoroscopy or echocardiography, has been only minimally reported. Indications for 3D-TSP remain unclear. Against this background, this study aims to establish a precise technique and create a workflow for validating and selecting eligible patients for fluoroless 3D-TSP. METHODS AND RESULTS: We developed a new methodology for 3D-TSP based on a unipolar electrogram derived from a transseptal needle tip (UEGM tip) in 102 patients (the derivation cohort) with intracardiac echocardiography (ICE) from March 2018 to February 2019. The apparent current of injury (COI) was recorded at the muscular limbus of the foramen ovalis (FO) on the UEGM tip (sinus rhythm: 2.57 ± 0.95 mV, atrial fibrillation: 1.92 ± 0.77 mV), which then disappeared or significantly reduced at the central FO. Changes in the COI, serving as a major criterion to establish a 3D-TSP workflow, proved to be the most valuable indicator for identifying the FO in 99% (101/102) of patients compared with three previous techniques (three minor criteria) of reduction in atrial unipolar or bipolar potential and FO protrusion. A total of 99.9% (1042/1043) patients in the validation cohort underwent successful 3D-TSP through the workflow from March 2019 to July 2023. Intracardiac echocardiography guidance was required for 6.6% (69/1042) of patients. All four criteria were met in 740 patients, resulting in a 100% pure fluoroless 3D-TSP success rate. CONCLUSION: In most patients, fluoroless 3D-TSP was successfully achieved using changes in the COI on the UEGM tip. Patients who met all four criteria were considered suitable for 3D-TSP, while those who met none required ICE guidance.

How are the predictors of sudden death modified after septal myectomy surgery?

BACKGROUND: Hypertrophic cardiomyopathy is a condition associated with an increased risk of sudden death compared to the general population. Extended septal myectomy surgery has been suggested to impact the reduction of sudden death events according to various publications. The aim of this study was to assess changes in the prevalence of sudden death predictors in a population of patients undergoing extended septal myectomy surgery. METHODS: Ninety-four consecutive patients underwent extended septal myectomy surgery due to symptomatic hypertrophic cardiomyopathy. Risk factors for sudden death, as defined by the American Heart Association and the European Society of Cardiology, were evaluated before and three months after surgery. RESULTS: The mean age of the population was 57 ± 13 years. A significant reduction was observed in the maximum septal thickness from 21.3 to 14 mm (p<0.001), along with a decrease in the anteroposterior diameter of the left atrium from 51 to 47 mm (p=0.021). Resting intraventricular gradients decreased from 49.2 to 6.4 mmHg (p<0.001), and Valsalva-induced gradients decreased from 93.9 to 8.7 mmHg (p<0.001). Non-sustained ventricular tachycardia decreased from 6% to 2% (p<0.001), and atrial fibrillation decreased from 30% to 15% (p<0.001). Ischemic behavior during exercise stress echo decreased from 6% to 0%, and the European Society of Cardiology sudden death risk score reduced from 3.32 to 1.44 (p<0.001). CONCLUSIONS: In this cohort of hypertrophic cardiomyopathy patients, extended septal myectomy surgery was associated with a reduction in the number and magnitude of sudden death predictors, potentially explaining the reduced mortality reported in the literature.

Percutaneous intramyocardial septal radiofrequency ablation after 5-year follow-up.

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.

Intracardiac echocardiography guided electrified J-wire trans-septal puncture: A prospective randomized controlled trial.

BACKGROUND: Application of electrocautery to a J-wire is used to perform transseptal puncture (TSP), but with limited evidence supporting safety and efficacy. We conducted a prospective randomized controlled trial to evaluate the safety and efficacy of this technique. METHODS: Two hundred consecutive patients were randomized in a 1:1 fashion to either the ICE-guided electrified J-wire TSP group or a conventional Brockenbrough (BRK) needle TSP group. The TSP was performed with a 0.032″ guidewire under 20 W, "coag" mode and was compared to TSP using the BRK needle. The primary safety endpoints were complications related to TSP. The primary efficacy endpoints included the TSP success rate, the total TSP time, and the total procedure time. RESULTS: All patients complete the procedure safely. The electrified J-wire TSP group had a significantly shorter TSP time than BRK needle TSP group. The total procedure time, number of TSP attempts required to achieve successful LA access, width of the intra-atrial shunt at the end of ablation were similar between the two groups. The incidence of new cerebral infarction detected by MRI were similar between the two groups (3/32 patients in the J-wire TSP group and 2/26 patients in conventional BRK TSP group, p = .82). And no difference in the incidence of residual intra-atrial shunt (4.3% vs. 6%, p = .654) during the 3-month's follow up. CONCLUSION: Using an electrified J-wire for TSP under the guidance of ICE appears to be as safe as and more efficient than conventional BRK needle TSP, which may be especially useful in the era of non-fluoroscopy AF ablation.

Improvement in gastrointestinal bleeding after septal myectomy for hypertrophic cardiomyopathy.

OBJECTIVE: Patients with obstructive hypertrophic cardiomyopathy may have occult gastrointestinal bleeding. In this study, we analyzed outcomes of septal myectomy in patients who had a history of gastrointestinal bleeding preoperatively to understand patient characteristics and impact of septal reduction on recurrent gastrointestinal bleeding. METHODS: We analyzed 73 adult patients who had a history of gastrointestinal bleeding before transaortic septal myectomy for obstructive hypertrophic cardiomyopathy and compared outcomes to 219 patients without gastrointestinal bleeding preoperatively. RESULTS: Patients with preoperative history of gastrointestinal bleeding were older (median (IQR) age, 65 (59-69) years, P < .001) and were more likely to have systemic hypertension (70% vs 53%, P = .020) and coronary artery disease (25% vs 13%, P = .026). Preoperatively, patients with gastrointestinal bleeding had a larger left atrial volume index (median, 53 mL/m2; interquartile range, 42-67; P = .006) and greater right ventricular systolic pressure (median, 36 mm Hg; interquartile range, 32-49; mm Hg, P = .005) but no significant difference in severity of outflow tract obstruction (P = .368). There were no perioperative deaths. The estimated 5- and 10-year survivals were 96.6% and 81.8%, respectively. At a median of 3.4 (interquartile range, 1.9-9.1) years after septal myectomy, 11 patients (15%) had recurrence of gastrointestinal bleeding, which was attributed to angiodysplasia or unknown causes in 6 patients (8%). CONCLUSIONS: Patients with a preoperative history of gastrointestinal bleeding have favorable short- and long-term outcomes after septal myectomy for obstructive hypertrophic cardiomyopathy. Remission of gastrointestinal bleeding was observed in 85% of patients postprocedure, and only 8% of the patients had recurrent gastrointestinal bleeding due to angiodysplasia or unknown causes.

Transapical beating-heart septal myectomy for hypertrophic cardiomyopathy with latent obstruction.

OBJECTIVES: A novel transapical beating-heart septal myectomy (TA-BSM) procedure was performed for patients with latent obstruction through the left intercostal incision and without cardiopulmonary bypass. This study aims to demonstrate the experience of the TA-BSM procedure for patients with latent obstruction and compare outcomes to patients with resting obstruction. METHODS: We studied 120 symptomatic hypertrophic obstructive cardiomyopathy patients (33 with latent obstruction and 87 with resting obstruction) who underwent TA-BSM. Demographic profiles, echocardiogram-derived ventricular morphology and haemodynamics and clinical outcomes were analysed. RESULTS: There were no important differences in baseline clinical characteristics between patients with latent obstruction and resting obstruction, including age, symptoms, comorbidities and medical history. Patients with latent obstruction had lower basal septum thickness, higher midventricular wall thickness, smaller left atrial chamber size and more frequency of mitral subvalvular anomalies. There was no difference in early (<30 days) deaths (0/33 vs 1/87, P > 0.999) and mid-term survival between patients with latent obstruction and resting obstruction. At 6 months after surgery, 31 (93.9%) patients with latent obstruction and 80 (92.0%) with resting obstruction achieved optimal procedural success, which was defined as a maximal gradient (after provocation) <30 mmHg and mitral regurgitation ≤ grade 1+ without mortality. Maximal left ventricular outflow tract gradient, basal septum thickness, midventricular wall thickness, mitral regurgitation grade and left atrial chamber size were significantly decreased after TA-BSM. In the follow-up, the New York Heart Association class was significantly improved following surgery. CONCLUSIONS: TA-BSM preserved favourable gold-standard guideline desired outcomes through real-time echocardiographic-guided resection. Equipoise of outcomes for this procedure regardless of degree of resting left ventricular outflow tract gradients supports operative management with this approach in symptomatic patients with latent obstruction.

Adding Surgical Edge-to-Edge Mitral Valve Repair to Myectomy in Hypertrophic Obstructive Cardiomyopathy: Long-Term Functional and Echocardiographic Outcome.

This study evaluates the early and long-term clinical and echocardiographic outcome of edge-to-edge (E2E) mitral valve repair (MVr) concomitant to septal myectomy (SM) in patients with symptomatic hypertrophic obstructive cardiomyopathy (HOCM). A retrospective single-center analysis was performed of patients who underwent isolated SM or SM with E2E MVr from 2011 to 2022. Exclusion criteria were primary mitral valve (MV) disease or concomitant valve surgery. Early and long-term safety, functional and echocardiographic outcomes were compared between groups. Between January 2011 and April 2022, 76 consecutive patients underwent SM for HOCM: 42 patients (55%) underwent SM without additional E2E MVr (Group 1) and 34 patients (45%) underwent SM with additional E2E MVr (Group 2). At latest follow-up, 87% of patients were in New York Heart Association (NYHA) class I-II with no significant differences in NYHA class between groups. Incidence of safety events was comparable between groups. Echocardiographic relief of left ventricular outflow tract (LVOT) obstruction was comparable at early follow-up (P = 0.68), with a significant but small difference in maximum LVOT pressure gradient at latest follow-up in favor of E2E MVr (P = 0.04). Furthermore, patients who underwent SM with E2E MVr showed less residual systolic anterior motion at early and latest follow-up (P = 0.020; P = 0.178). Reintervention on the MV was absent in both groups at 1 year and equally low at follow-up (P = 0.27). This study demonstrates that adding E2E MVr to septal myectomy is as safe as isolated myectomy for the treatment of HOCM. Moreover, the addition of E2E MVr is associated with similar excellent functional improvement and freedom from MV reintervention.

First-in-Human Transapical Beating-Heart Septal Myectomy in Patients With Hypertrophic Obstructive Cardiomyopathy.

BACKGROUND: To simplify surgical septal reduction therapy for hypertrophic obstructive cardiomyopathy (HOCM), we developed a novel transapical beating-heart septal myectomy (TA-BSM) procedure. OBJECTIVES: In this study, we sought to evaluate the clinical utility of TA-BSM in a first-in-human trial. METHODS: Patients with HOCM were enrolled if they presented with drug-refractory disabling symptoms. TA-BSM was performed via minithoracotomy with the use of our beating-heart myectomy device under echocardiographic guidance, without the use of cardiopulmonary bypass. Repeated resections were performed to tailor the extent of the septal myectomy for sufficient abolishment of left ventricular outflow tract (LVOT) obstruction and mitral regurgitation (MR). The primary outcome measure was procedural success, defined by resting/provoked LVOT gradient <30/50 mm Hg and residual MR grade ≤1+ (of 4+) at 3-month follow-up. RESULTS: A total of 47 patients aged 12 to 77 years were enrolled. Of the 46 patients who were followed for 3 months, 42 achieved procedural success. The maximal LVOT gradient decreased from 86 mm Hg (IQR: 67-114 mm Hg) at baseline to 19 mm Hg (IQR: 14-28 mm Hg) at 3 months. MR grade was ≤1+ in 3 patients at baseline and in 45 patients at 3 months. One patient died on postoperative day 10 owing to device-unrelated reasons. Other major adverse events included 1 delayed ventricular septal perforation and 1 intraoperative left ventricular apical tear. CONCLUSIONS: TA-BSM is a safe and efficient minimally invasive procedure for septal reduction of heterogeneous HOCM. Compared with conventional septal myectomy, TA-BSM provides real-time evaluation to guide resection while reducing surgical trauma. (Transapical Beating-Heart Septal Myectomy in Patients With Hypertrophic Obstructive Cardiomyopathy; NCT05332691).

Echocardiographic Patterns of Abnormal Septal Motion: Beyond Myocardial Ischemia.

Abnormal septal motion (ASM), which often is associated with myocardial ischemia, is also observed in other diseases. Owing to the position of the interventricular septum (IVS) in the heart, its movement not only relies on contractile properties but is also affected by the pressure gradient between the 2 ventricles and by the mode of electrical activation. Echocardiography allows the operator to focus on the motion of the IVS, analyzing its characteristics and thereby gaining information about the possible underlying pathophysiological mechanism. In this review, we focused on the main echocardiographic patterns of ASM that are not related to a failure of contractile properties of the septum (i.e., acute coronary syndrome and cardiomyopathies), showing their pathophysiological mechanisms and underlining their diagnostic usefulness in clinical practice.

Hospital Procedural Volume and Clinical Outcomes Following Septal Reduction Therapy in Obstructive Hypertrophic Cardiomyopathy.

Background Prior national data showed a substantial in-hospital mortality in septal myectomy (SM) with an inverse volume-outcomes relationship. This study sought to assess the contemporary outcomes of septal reduction therapy and volume-outcome relationship in obstructive hypertrophic cardiomyopathy. Methods and Results All septal reduction therapy admissions between 2010 to 2019 in the United States were analyzed using the National Readmission Databases. Hospitals were stratified into tertiles of low-, medium-, and high-volume based on annualized procedural volume of alcohol septal ablation and SM. Of 19 007 patients with obstructive hypertrophic cardiomyopathy who underwent septal reduction therapy, 12 065 (63%) had SM. Two-thirds of hospitals performed ≤5 SM or alcohol septal ablation annually. In all SM encounters, 482 patients (4.0%) died in-hospital post-SM. In-hospital mortality was <1% in 1505 (88.4%) hospitals, 1% to 10% in 30 (1.8%) hospitals, and ≥10% in 167 (9.8%) hospitals. There were 63 (3.7%) hospitals (averaging 2.2 SM cases/year) with 100% in-hospital mortality. Post-SM (in low-, medium-, and high-volume centers, respectively), in-hospital mortality (5.7% versus 3.9% versus 2.4%, P=0.003; adjusted odds ratio [aOR], 2.86 [95% CI, 1.70-4.80], P=0.001), adverse in-hospital events (21.30% versus 18.0% versus 12.6%, P=0.001; aOR, 1.88 [95% CI, 1.45-2.43], P=0.001), and 30-day readmission (17.1% versus 12.9% versus 9.7%, P=0.001; adjusted hazard ratio, 1.53 [95% CI, 1.27-1.96], P=0.001) were significantly higher in low- versus high-volume hospitals. For alcohol septal ablation, the incidence of in-hospital death and all other outcomes did not differ by hospital volume. Conclusions In-hospital SM mortality was 4% with an inverse volume-mortality relationship. Mortality post-alcohol septal ablation was similar across all volume tertiles. Morbidity associated with SM was substantial across all volume tertiles.

Septal Myectomy or Alcohol Ablation for Hypertrophic Cardiomyopathy: A Nationwide Inpatient Sample (NIS) Database Analysis.

BACKGROUND: Comparison of the real-world cohort on the relative safety of alcohol septal ablation (ASA) vs. septal myectomy (SM) for the management of hypertrophic cardiomyopathy (HCM) has been lacking. METHODS: The National Inpatient Sample (NIS) (2012-2019) was used to select all cases of HCM. The safety of ASA vs. SM was compared using a one:many propensity score matched (PSM) analysis. Adjusted odds ratios (aOR) for mortality and other in-hospital complications were computed. RESULTS: A total of 6208 HCM patients (ASA 3106 vs. SM 3102) were included using a PSM analysis. Post-procedural bleeding (aOR 0.18, 95 % CI 0.11-0.32, p < 0.0001) and the need for an intra-aortic balloon pump (aOR 0.51, 95 % CI, 0.28-0.96, p = 0.037) were significantly lower while permanent pacemaker (PPM) implantation was significantly higher in ASA group as compared with SM group (aOR 1.72, 95 % CI, 1.43-2.06, p < 0.0001). The total in-hospital mean adjusted cost and length of stay were also significantly lower in the ASA group. However, there were no significant differences in adjusted odds of all-cause mortality (aOR 0.91, 95 % CI 0.62-1.33, p = 0.61), stroke (aOR 0.91, 95 % CI, 0.59-1.4, p = 0.66), and major bleeding (aOR 1.0, 95 % CI 7.8-1.29, p = 0.99) between the two comparison groups. CONCLUSION: In patients with hypertrophic cardiomyopathy, alcohol septal ablation appears to be an acceptable alternative to septal myectomy due to a lower risk of post-procedural bleeding and the need for an intra-aortic balloon pump. However, ASA confers a higher risk of PPM placement.

Myocardial mechanics of percutaneous intramyocardial septal radiofrequency ablation.

OBJECTIVE: Echocardiography-guided Percutaneous IntraMyocardial Septal Radiofrequency Ablation (PIMSRA, Liwen procedure) is a novel treatment option for hypertrophic obstructive cardiomyopathy (HOCM). The impact of PIMSRA on myocardial mechanics is unknown. METHODS: Between October 2016 and June 2019, PIMSRA and 3-dimentional speckle tracking echocardiography were performed in 82 patients. Echocardiographic imaging, qualitative and quantitative clinical assessment were completed at baseline, immediately postprocedure and 1-year follow-up. RESULTS: There was a significant reduction in the peak left ventricular outflow tract (LVOT) gradients immediately following PIMSRA and at 1-year follow-up (resting gradients: from 83.50 (61.25) to 23.00 (41.75) mm Hg, p<0.001 and 13.50 (21.75) mm Hg, p<0.001, respectively; stress-induced gradients: from 118.25 (96.02) to 47.00 (74.50) mm Hg (1 year), p<0.001). There was an improvement in exercise time on stress echocardiography (p<0.001) and distance by 6 min walk test (p=0.034). Immediately after PIMSRA, there was a significant reduction in radial and circumferential strain in the ablated segments (p<0.001), with no change of longitudinal strain. At 1-year follow-up, the radial and circumferential strain recovered in the ablated segments. Meanwhile, left ventricular regional and global longitudinal strain had improved significantly (p<0.05). CONCLUSIONS: PIMSRA is an effective treatment for symptomatic HOCM that resulted in a sustained improvement in exercise capacity, a persistent decrease in LVOT gradient, and a measurable increase in myocardial contractile function. TRIAL REGISTRATION NUMBER: NCT04777188.

Preoperative left ventricular longitudinal strain predicts outcome of septal myectomy for obstructive hypertrophic cardiomyopathy.

OBJECTIVE: The objective of this study was to determine the characteristics of longitudinal strain and its effect on outcomes in patients with obstructive hypertrophic cardiomyopathy (HCM) who underwent septal myectomy. METHODS: We reviewed patients with obstructive HCM who underwent septal myectomy at our clinic from 2007 to 2016. Data of those who had strain echocardiography within 6 months before isolated myectomy were analyzed. RESULTS: The median age of the 857 patients studied was 55 (interquartile range [IQR], 44-63) years, and 451 (52.6%) were male. Left ventricular ejection fraction was 71% (IQR, 67%-74%), and the resting peak outflow tract gradient was 58 (IQR, 27-85) mm Hg. The median global longitudinal strain (GLS) was -14.6% (IQR, -12.0% to -17.3%). Regional longitudinal strain was nonuniform as reflected by more normal values in apical segments and more abnormal in basal segments. Moreover, GLS correlated poorly with ejection fraction and outflow tract gradient. In 64 patients who had postoperative strain echocardiography, GLS was comparable before and after septal myectomy, but regional strain was more uniform after myectomy. Over a follow-up of 8.3 (IQR, 6.5-10.3) years, when patients were equally stratified according to GLS (cutoff, -14.64%), the group with worse GLS had significantly poorer survival compared with the better GLS group (P = .002). Left ventricular ejection fraction had no association with survival. CONCLUSIONS: Left ventricular longitudinal strain is nonuniform and might be significantly reduced in patients with obstructive HCM. Septal myectomy does not impair GLS but is associated with more uniform regional strains. Most importantly, reduced GLS preoperatively is strongly and independently associated with increased all-cause mortality after septal myectomy for obstructive HCM.

Outcomes of Patients With Hypertrophic Obstructive Cardiomyopathy and Pacemaker Implanted After Alcohol Septal Ablation.

BACKGROUND: Atrioventricular block is a frequent major complication after alcohol septal ablation (ASA). OBJECTIVES: The aim of this study was to evaluate the outcomes of patients with implanted permanent pacemaker (PPM) related to a high-grade atrioventricular block after ASA for hypertrophic obstructive cardiomyopathy. METHODS: We used a multinational registry (the Euro-ASA registry) to evaluate the outcome of patients with PPM after ASA. RESULTS: A total of 1,814 patients were enrolled and followed up for 5.0 ± 4.3 years (median = 4.0 years). A total of 170 (9.4%) patients underwent PPM implantation during the first 30 days after ASA. Using propensity score matching, 139 pairs (n = 278) constituted the matched PPM and non-PPM groups. Between the matched groups, there were no long-term differences in New York Heart Association functional class (1.5 ± 0.7 vs 1.5 ± 0.9, P = 0.99) and survival (log-rank P = 0.47). Patients in the matched PPM group had lower long-term left ventricular (LV) outflow gradient (12 ± 12 mm Hg vs 17 ± 19 mm Hg, P < 0.01), more pronounced LV outflow gradient decrease (81% ± 17% vs 72% ± 35%, P < 0.01), and lower LV ejection fraction (64% ± 8% vs 66% ± 8%, P = 0.02) and were less likely to undergo reintervention (re-ASA or myectomy) (log-rank P = 0.02). CONCLUSIONS: Patients with hypertrophic obstructive cardiomyopathy treated with ASA have a 9% probability of PPM implantation within 30 days after ASA. In long-term follow-up, patients with PPM had similar long-term survival and New York Heart Association functional class but lower LV outflow gradient, a more pronounced LV outflow gradient decrease, a lower LV ejection fraction, and a lower likelihood of reintervention compared with patients without PPM.

Sex-related differences in left ventricular remodeling and outcome after alcohol septal ablation in hypertrophic obstructive cardiomyopathy: insights from cardiovascular magnetic resonance imaging.

BACKGROUND: Alcohol septal ablation (ASA) has been proven to reverse left ventricular (LV) remodeling in hypertrophic cardiomyopathy (HCM). However, there are no studies on the effect of sex on LV remodeling after ASA. We aimed to investigate whether sex differences affect the process of LV remodeling and outcome after ASA. METHODS: A total of 107 patients with obstructive HCM (54 men and 53 women, mean age 51 ± 8 years) were recruited. Cardiovascular magnetic resonance (CMR) was performed at baseline and 16 months after ASA. The extent of late gadolinium enhancement (LGE) was measured. RESULTS: Women had a higher indexed LV mass and smaller indexed LV end-systolic volumes than men at the time of ASA. After ASA, both men and women exhibited a regression of LV mass, and the percentage of mass regression was greater in men than women (15.3% ± 4.3% vs. 10.7% ± 1.8%, p < 0.001). In multivariable analysis, male sex, higher reduction of LV outflow tract (LVOT) gradient and lower baseline LV mass index were independently associated with greater LV mass regression after ASA. Kaplan-Meier analysis showed significantly higher cardiovascular events in women than in men (p = 0.015). Female sex [hazard ratio (HR) 3.913, p = 0.038] and LV mass preablation (HR, 1.019, p = 0.010) were independent predictors of cardiovascular outcomes. CONCLUSIONS: Males with HCM had favorable reverse remodeling with greater LV mass regression post-ASA than female patients. This favorable LV reverse remodeling might provide a mechanistic explanation for the survival advantage in men.

Real-world clinical outcomes of percutaneous transluminal septal myocardial ablation for patients with drug-refractory hypertrophic obstructive cardiomyopathy: results from a retrospective multicenter registry of non-high-volume centers.

Percutaneous transluminal septal myocardial ablation (PTSMA) is a well-established interventional therapy for drug-refractory hypertrophic obstructive cardiomyopathy (HOCM) as an alternative to surgical myectomy. Although guidelines recommend that PTSMA should be performed in institutions with extensive experience, it is not centralized to such high-volume centers in real-world clinical practice. Thus, this study aimed to assess the feasibility of PTSMA in non-high-volume centers. We retrospectively examined patients with HOCM who underwent PTSMA between August 2012 and May 2020 at four institutions that experienced fewer than 20 cases of PTSMA procedures. The primary clinical endpoint was a composite of safety (all-cause death, electrical defibrillation for ventricular tachycardia or fibrillation, cardiac tamponade, permanent pacemaker implantation, and repeated interventions) and efficacy endpoints (repeated interventions [PTSMA or surgical myectomy]). Fifty-eight consecutive patients were enrolled. During the 30-day follow-up, no major clinical adverse events were noted except three patients (5.2%) requiring permanent pacemaker implantation for complete atrioventricular block. The percentage of patients with New York Heart Association functional class 1 or 2 significantly increased from 8.6 to 100% (p < 0.001). In the Cox proportional hazard model, left ventricular outflow tract pressure gradient at rest ≥ 30 mmHg (hazard ratio [HR] 6.56; 95% confidence interval [CI] 1.44-29.90; p = 0.015) and mitral regurgitation grade ≥ 3 (HR 10.75; 95% CI 1.81-63.79; p = 0.009) at the 30-day follow-up were associated with a composite of major clinical adverse events. The current study demonstrated that 58 patients who underwent PTSMA in non-high-volume centers had favorable 30-day clinical outcomes, with a primary composite endpoint rate of 5.2%. A prospective study with a larger sample size and longer follow-up is warranted to verify the safety and efficacy of PTSMA in non-high-volume centers.

Transapical Ventricular Remodeling for Hypertrophic Cardiomyopathy With Systolic Cavity Obliteration.

BACKGROUND: Some patients with hypertrophic cardiomyopathy (HCM) present with reduced left ventricular (LV) stroke volume and elongated systolic cavity obliteration due to symmetric LV hypertrophy. In this report, we detail our experience with transapical septal myectomy to enlarge the LV volume and to relieve cavity obliteration in this unique subgroup of patients with HCM. METHODS: We analyzed 38 patients with HCM who had extended symmetric LV hypertrophy and underwent transapical septal myectomy to enlarge the LV cavity from February 2001 to May 2021. RESULTS: At the time of evaluation for operation, 84.2% (n = 32) of the patients were in New York Heart Association class III/IV. The peak oxygen consumption was 51.5% (44.0%-58.0%) of the normal predicted values on the preoperative exercise stress test (n = 16). Preoperative left atrial sizes in this cohort were enlarged (left atrial volume index, 39.0 [33.5-51.5] mL/m2), despite only 4 patients with moderate or greater mitral valve regurgitation. All patients underwent transapical septal myectomy to enlarge the LV cavity size. There was no postoperative (within 30 days) death. During a median (interquartile range) follow-up of 3.4 (0.7-6.9) years, the estimated survival rates were 100%, 92%, and 87% at 1, 3, and 5 years, respectively. Follow-up surveys suggested that 16 of the 17 contacted patients experienced improvement in their heart function after the procedure. CONCLUSIONS: Transapical myectomy to enlarge LV cavity volume can be performed safely with good early survival and functional results. This procedure is an important alternative to cardiac transplantation for HCM patients with systolic cavity obliteration and progressive heart failure.

Transapical septal myectomy for hypertrophic cardiomyopathy, an experience from Japan.

BACKGROUND: While there are a variety of surgical options for hypertrophic cardiomyopathy, there are small number of reports of transapical septal myectomy. Furthermore, the characteristics and incidence of anomalous structures in the left ventricle in hypertrophic cardiomyopathy patients which can be identified with imaging studies are not clear. METHODS: We studied hypertrophic cardiomyopathy patients who underwent transapical septal myectomy from July 2013 to December 2019. We evaluated the frequency and characteristics of anomalous structures in the left ventricle which had been identified by preoperative examinations and studied their postoperative results. RESULTS: A total of 59 patients was included. The median age was 40 years. Sixteen patients (27.4%) were in New York Heart Association Functional Classification III or IV. The median peak intraventricular gradient at rest was 65 mmHg. By preoperative imaging studies, anomalous structures were detected in 56 cases (94.9%), of which 88% were successfully resected with myectomy. There were two perioperative deaths, while one late death caused by acute myocardial infarction occurred. The estimated 5-year survival rate was 95%. The intraventricular gradient had significantly decreased at the time of discharge, and no reoperation for recurrent obstruction was conducted. The left ventricular ejection fraction had significantly decreased after the operation, was however within the normal range. Left atrium volume index and tricuspid regurgitant velocity significantly improved. CONCLUSIONS: Patients receiving transapical septal myectomy restored good hemodynamics from early postoperative period and showed improved subjective symptoms and good mid-term results. With multimodal imaging studies, we could accurately identify anomalous structures in hypertrophic cardiomyopathy patients and reliably treat them by transapical septal myectomy.