A Systematic Review and Meta-Analysis of Long-Term Outcomes After Septal Reduction Therapy in Patients With Hypertrophic Cardiomyopathy

Our understanding of hypertrophic cardiomyopathy (HCM) as a disease entity has increased dramatically over the last half century. There has been a concerted effort by several surgical groups to develop operative techniques to relieve left ventricular outflow tract (LVOT) obstruction and alleviate symptoms. This paper traces the development of transaortic septal myectomy, the current gold standard therapy for relief of LVOT obstruction, in symptomatic patients refractory to medical treatment. In addition, we introduce newer methods for myectomy that have expanded the role of surgery in patients with various forms of HCM.

Section: Ablation Versus Myectomysupporting

confidence: 69%

Surgical treatment for hypertrophic cardiomyopathy: a historical perspective

Hang

Nguyen

Schaff

2017

“…In particular, alcohol ablation requires a shorter hospital admission and recovery time than surgery and is associated with less postoperative disability. In the last decade, a large body of literature (including a number of meta-analyses) has reported the results of this procedure (13,(22)(23)(24)(25)(26). Alcohol septal ablation can often relieve obstruction and improve symptoms (at least during an intermediate period of follow-up) when performed in properly selected patients by interventional cardiovascular specialists with extensive experience with this procedure (13,22,24,25).…”

Section: Alcohol Septal Ablationmentioning

confidence: 99%

Alcohol septal ablation: in which patients and why?

Spirito¹,

Rossi²,

Maron³

2017

At present, surgical septal myectomy is regarded as the "gold standard" treatment for most patients with obstructive hypertrophic cardiomyopathy (HCM) and drug-refractory symptoms. However, the best results are obtained by those surgeons who have extensive experience with this operation at a small number of referral centers. In the mid-1990s, percutaneous alcohol septal ablation was introduced as an alternative to myectomy to reduce LV outflow gradient and heart failure symptoms in patients with obstructive HCM. However, certain features of alcohol ablation limit its applicability to carefully selected patients.Because this procedure involves the injection of 1-4 mL of 96% ethanol into a septal perforator of the left anterior coronary artery to produce a myocardial infarction (with septal thinning, outflow tract widening and gradient reduction), alcohol ablation is limited by the size and distribution of the septal perforator branches. In addition, rich blood supply from other septal branches not occluded by the balloon and from the posterior descending coronary artery may restrict myocardial ischemia to portions of the septum that do not contribute to outflow obstruction. Septal hypertrophy may be either mild or particularly marked, and abnormalities of mitral valve apparatus may also play a major role in outflow obstruction. When such features are present, alcohol-induced septal thinning is unlikely to significantly reduce the gradient. In addition, persisting uncertainties regarding the risk for ventricular tachyarrhythmias after alcohol ablation suggest this procedure should be limited to patients of advanced age, patients at unacceptable operative risk due to comorbidities, or those with strong aversion to surgery. Further progress in the treatment for patients with obstructive HCM and severe refractory symptoms will come from assuring proper patient selection for alcohol septal ablation, as well as increasing the number of surgeons and centers experienced in performing septal myectomy. PerspectiveIn patients with hypertrophic cardiomyopathy (HCM), left ventricular (LV) outflow obstruction with a pressure gradient between the LV outflow tract and aorta is caused by systolic anterior motion of the mitral valve against the septum (1), and is identified at rest or with physiologic exercise in about 70% of patients evaluated at tertiary referral centers (2). Obstruction to LV outflow obstruction is associated with mitral valve regurgitation, disabling heart failure symptoms and increased cardiovascular mortality (3,4). For almost 50 years, transaortic septal myectomy has represented the standard surgical approach for the treatment of patients with obstructive HCM and severe symptoms refractory to medical treatment (1,5-7).In the mid-1990s, percutaneous alcohol septal ablation was introduced as an alternative to surgical myectomy to reduce the LV outflow gradient and heart failure symptoms in patients with obstructive HCM (8). This catheterbased procedure, made attractive by its less invasive nature, was rapidl...

“…In the most recent registries (10,11), the percentage of patients who are lost at gradient/symptomatic follow-up or suffering obstruction requiring repeated SRT is 15-18%. Such numbers should be taken in serious considerations especially in view of the aforementioned limited follow-up in ASA and with the low rates of reoperation after septal myectomy that nowadays are well below 2% (21).…”

Section: Introductionmentioning

confidence: 99%

Septal myectomy after failed septal alcohol ablation

Bajona

Arguís

Prat‐González

2017

Despite septal myectomy remaining the gold standard septal reduction therapy for hypertrophic obstructive cardiomyopathy (HOCM), there has been a disproportionate use of alcohol septal ablation (ASA) worldwide.Absolute resolution of left ventricular outflow tract (LVOT) obstruction with ASA is not achieved in a substantial proportion of patients. The mechanisms of failure from ASA are partially understood and described. Residual obstruction in hypertrophic cardiomyopathy is associated with worse clinical outcomes and mortality. There is a growing number of patients who present with significant residual gradients after ASA and require a rescue septal myectomy operation, which then carries an increased risk of perioperative complications and life-long sequelae. This contrasts with the excellent outcomes achieved by septal myectomy without previous percutaneous intervention. Despite complete resolution of obstruction in rescue myectomy, the outcomes remain compromised by the prior ASA.