Summary Cardiac resynchronization therapy (CRT) has rapidly evolved as a standard therapy for heart failure (HF) patients with ventricular conduction delay. Although in early trials, only patients with sinus rhythm and advanced stages of HF have been candidates for CRT, more recent data have expanded the indications to patients with mild-to-moderate HF and atrial fibrillation and patients in need of antibradycardia pacing with reduced left ventricular function. On the other hand, it is now well recognized that patients with a wide QRS (>150 ms) and left bundle branch block morphology benefit most from CRT, whereas in patients with a more narrow QRS complex (<130 ms) CRT may actually be harmful despite the evidence of ventricular dyssynchrony by echocardiography. There is no prospective randomized study showing mortality benefit from a combined CRT defibrillating device over a CRT pacer alone. This is especially important because recent data indicate that older patients with non-ischaemic cardiomyopathy may not benefit from the implantable cardioverter-defibrillator as much as previously thought. Thus, the decision for a CRT pacer versus CRT defibrillating should be tailored to the therapeutic goal (improvement in prognosis versus symptomatic relief), patient age, underlying cardiac disease and comorbidities. This article gives an overview over the current indications for CRT according to published literature and the European guidelines for pacing and HF.

Introduction Endocardial radiofrequency ablation of septal hypertrophy (ERASH) is an alternative to alcohol septal ablation (ASA) or surgical myectomy for hypertrophic obstructive cardiomyopathy (HOCM). Several studies have confirmed that septal radiofrequency ablation leads to a significant reduction in the left ventricular outflow tract gradient. Objectives We aimed to report the outcomes of 41 patients who underwent ERASH with a focus on severe complications. Methods Since 2004, 41 patients with HOCM (age: 58.2 ± 13 years) underwent ERASH at our institution. ERASH was performed, since ASA was ineffective (26 patients) or not possible (15 patients). Results The left ventricular outflow tract and the right ventricular septum were ablated in 26 and 15 patients, respectively. ERASH resulted in a significant reduction in acute gradient during the session and the results persisted during the 6‐month follow‐up (67% gradient reduction at rest and 73% after provocation, p = .0002). Pacemaker dependency after ERASH was 29% and pericardial tamponade occurred in two patients. In four patients, ERASH induced a paradoxical increase in obstruction (PIO), beginning suddenly at 30 min after the procedure and leading to lethal shock in one patient. PIO was not observed after ERASH from the right ventricular aspect. Conclusion Morbidity and mortality after ERASH were higher than those after ASA. PIO, a life‐threatening complication, was observed in 9% of the patients. Our data indicate that ERASH might be considered in patients who are not candidates for surgical myectomy or ASA.

No abstract

No abstract

ObjectiveAlcohol septal ablation (ASA) improves symptoms in hypertrophic obstructive cardiomyopathy (HOCM). We conducted a large retrospective analysis investigating gender effects on outcome after ASA.Methods and results1367 ASAs between 2002 and 2020 were analysed. Women (47.2%) were older (66.0 years (IQR 55.0–74.0) vs 54.0 years (IQR 45.0–62.0); p<0.0001) with more severe symptoms. The interventricular septal diameter (IVSD) was higher in men (21.0 mm (IQR 19.0–24.0) vs 20.0 mm (IQR 18.0–23.0); p<0.0001) but the IVSD indexed to body surface area was higher in women (10.9 mm/m2 (IQR 9.7–12.7) vs 10.2 mm/m2 (IQR 9.0–11.7); p<0.0001). Women had lower exercise-induced left ventricular outflow tract gradients (LVOTG) 1–4 days after ASA (55.0 mm Hg (IQR 30.0–109.0) vs 71.0 mm Hg (IQR 37.0–115.0); p=0.0006). There was a trend for lower resting LVOTG 1–4 days after ASA (20.0 mm Hg (IQR 12.0–37.5) vs 22.0 mm Hg (IQR 13.0–40.0); p=0.0062) and lower exercise-induced LVOTG after 6 months in women (34.0 mm Hg (IQR 21.0–70.0) vs 43.5 mm Hg (IQR 25.0–74.8); p=0.0072), but this was not statistically significant after Bonferroni correction. More women developed atrioventricular (AV) block (20.3% vs 13.3%; p=0.0005) and required a pacemaker (17.4% vs 10.4%; p=0.0002) but not a cardioverter defibrillator (9.0% vs 11.6% in men; p=n .s.). However, in multivariable regression models, there was no evidence that sex independently influenced LVOTG and the occurrence of AV block.ConclusionFemale patients with HOCM were older and had more advanced disease at the time of ASA. Women had superior short-term haemodynamic response to ASA but more often developed AV block after ASA. These results are important to consider for sex-specific counselling before ASA.