Predictors of outcome after alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy. Special interest for the septal coronary anatomy

Abstract

BackgroundAlcohol septal ablation (ASA) provides symptomatic relief in most but not all patients with hypertrophic obstructive cardiomyopathy (HOCM). Therefore we investigated predictors of outcome after ASA.MethodsClinical, echocardiographic, angiographic and procedural characteristics were analysed in 113 consecutive patients. Successful ASA was defined as NYHA ≤ 2 with improvement of at least 1 class combined with a resting gradient < 30 mmHg and provoked gradient < 50 mmHg at 4-month follow-up.ResultsIn 37 patients ASA was not successful. In multivariate analysis, baseline gradient (OR 1.06 (1.01–1.11) per 5 mmHg, p = 0.024) and distance to the ablated septal branch (OR 1.09 (1.03–1.16) per mm, p = 0.004) were predictors of unsuccessful outcome. The combined presence of a non-ablated septal branch and a distance ≥ 19 mm to the ablated branch was a predictor of unsuccessful outcome (OR 5.88 (2.06–16.7), p < 0.001).ConclusionsBaseline gradient and a greater distance from the origin of the left anterior descending artery to the ablated septal branch combined with a non-ablated proximal septal branch are associated with an unsuccessful outcome after ASA.

Alcohol septal ablation: A useful tool in our arsenal against hypertrophic obstructive cardiomyopathy

“…Thirty‐seven out of 113 were deemed to have insufficient response to ASA; elevated resting gradient, and greater distances from the origin of the LAD artery to the first septal branch were shown to be associated with poorer outcomes. Suggesting that unfavorable coronary anatomy may result in either insufficient therapeutic effect, or increased chances of the procedure being abandoned 37 . Less common periprocedural complications include coronary artery dissection, cardiac tamponade, and arterial complications which are related to access, such as femoral artery pseudoaneurysm or retroperitoneal hemorrhage 38 .…”

Through Thick and Thin

“…Given the multitude of pre-, intra-, and postprocedural factors, including age, 7 baseline LVOT gradient, 7,8 coronary anatomy 8 and pathoanatomy, 15 immediate postablation gradient, 6,7 and peak creatine kinase, 6 that may influence the hemodynamic and clinical success of septal ablation, it is perhaps not surprising that it has been difficult to isolate baseline septal thickness as a predictor of success. The current study thus advances our ability to predict success and, therefore, to select patients for alcohol septal ablation.…”

video 1

“…Unable to determine tip position of the anterior leaflet in relation to the interventricular septum Target In most cases, the images obtained are deemed to be of sufficient quality to comment on the localisation of contrast and likely alcohol distribution. However, a significant proportion of ASA procedures fail to resolve the LVOT gradient (6,15,16). This is usually due to inaccurate location of the iatrogenic infarct (9).…”