Myectomy versus alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy

Abstract

OBJECTIVES There is very little evidence comparing the safety and efficacy of alcohol septal ablation versus septal myectomy for a septal reduction in patients with hypertrophic obstructive cardiomyopathy. This study aimed to compare the immediate and long-term outcomes of these procedures. METHODS Following propensity score matching, we retrospectively analysed outcomes in 105 patients who underwent myectomy and 105 who underwent septal ablation between 2011 and 2017 at 2 reference centres. RESULTS The mean age was 51.9 ± 14.3 and 52.2 ± 14.3 years in the myectomy and ablation groups, respectively (P = 0.855), and postoperative left ventricular outflow tract gradients were 13 (10–19) mmHg vs 16 (12–26) mmHg; P = 0.025. The 1-year prevalence of the New York Heart Association class III–IV was higher in the ablation group (none vs 6.4%; P = 0.041). The 5-year overall survival rate [96.8% (86.3–99.3) after myectomy and 93.5% (85.9–97.1) after ablation; P = 0.103] and cumulative incidence of sudden cardiac death [0% and 1.9% (0.5–7.5), respectively P = 0.797] did not differ between the groups. The cumulative reoperation rate within 5 years was lower after myectomy than after ablation [2.0% (0.5–7.6) vs 14.6% (8.6–24.1); P = 0.003]. Ablation was associated with a higher reoperation risk (subdistributional hazard ratio = 5.9; 95% confidence interval 1.3–26.3, P = 0.020). At follow-up, left ventricular outflow tract gradient [16 (11–20) vs 23 (15–59) mmHg; P < 0.001] and prevalence of 2+ mitral regurgitation (1.1% vs 10.6%; P = 0.016) were lower after myectomy than after ablation. CONCLUSIONS Both procedures improved functional capacity; however, myectomy better-resolved classes III–IV of heart failure. Septal ablation was associated with higher reoperation rates. Myectomy demonstrated benefits in gradient relief and mitral regurgitation elimination. The results suggest that decreasing rates of myectomy procedures need to be investigated and reconsidered.

Early post-septal myectomy outcomes for hypertrophic obstructive cardiomyopathy

“…Similar findings were underlined in a systematic review by Poon et al 17 and in a Dutch meta-analysis. 18 Notably, in an era of less invasive procedures (such as ASA) and limited ASA success relative to SM, 16,19 patients referred for SM, due to ASA failure, may likely undergo permanent pacemaker implantation.…”

Alcohol Septal Ablation: An Option on the Rise in Hypertrophic Obstructive Cardiomyopathy

“…However, compared with SM, septal ablation has been associated with a lower decrease in the LVOT gradient, less improvement in symptoms, higher pacemaker implantation and a higher frequency of reinvention. [ 25 , 37 , 49 ]…”

“…The size of the balloon should generally be short (1.5–2.5 mm in diameter, 6–10 mm in length, and with a balloon-artery ratio of 1.3:1 approximately or usually 0.25 mm greater than the vessel diameter). Short balloons are recommended to avoid hyperselectivity in the presence of a septal branch with early bifurcation [ 26 , 37 ]. After placing the balloon, the guidewire is removed.…”

A novel risk model to predict all-cause mortality in patients undergoing percutaneous transluminal septal myocardial ablation for hypertrophic obstructive cardiomyopathy

“…PTSMA was conducted after careful evaluation by a multidisciplinary team, as described previously [11,12] . Blood samples were obtained in the 24 hours post-PTSMA to determine the cardiac infarction of creatine kinase-MB (CK-MB) and troponin-I.…”