Surgical septal myectomy outcome for obstructive hypertrophic cardiomyopathy after alcohol septal ablation

Abstract

Background: Although surgical treatment of residual obstruction after alcohol septal ablation (ASA) is often challenging in patients with obstructive hypertrophic cardiomyopathy (OHCM) there are very few relevant clinical reports. Thus, outcomes of surgical septal myectomy (SSM) in this subgroup of patients remain to be determined. Therefore, this study aimed to determine the surgical and follow-up outcomes in patients with OHCM exhibiting residual obstruction after ASA. Methods: We collected case data for 62 patients with OHCM and residual obstruction after ASA who underwent SSM at Fuwai Hospital between January 2002 and June 2019. Propensity score matching with patients having had a myectomy as the only invasive procedure-was conducted in a 1:2 ratio.Echocardiography parameters, surgery results, and follow-up outcomes were compared between the groups. Results: The prior ASA group had a higher incidence of complete atrioventricular block (AVB) and subsequently postoperative permanent pacemaker (PPM) implantation than the primary myectomy group (9.7% vs. 1.6%, P=0.01). Two patients died within 30 days after surgery in the prior ASA group, and one patient died in the primary myectomy group, with an operative mortality rate of 3.2% and 0.8%, respectively (P=0.2). The 5-year event-free survival rate was 86.0% in the prior ASA group (median follow-up period: 3.2 years; mean: 3.9±2.6 years; maximum, 10.6 years) and 88.5% in the primary myectomy group (median follow-up period: 2.4 years; mean 2.8±1.7 years; maximum, 9.1 years) (P=0.2). During follow-up, four of 62 (6.5%) patients in the prior ASA group and one of 124 (0.8%) patients in the primary myectomy group progressed to advanced heart failure (P=0.025). Conclusions: Patients with OHCM following ASA are at an increased risk of developing AVB after SSM.Their surgical outcomes, and long-term survival rate were satisfactory and, osimilar to those for patients having had a myectomy as the only invasive procedure. In addition, they had an increased risk of advanced heart failure after SSM in the present study.

Percutaneous Intramyocardial Septal Radiofrequency Ablation Relieving Residual Left Ventricular Outflow Tract Obstruction Following Alcohol Septal Ablation

“…However, the blood supply of the septum is so abundant and highly variable and includes all other septal branches as well as the posterior descending artery, 4 leading to an unsatisfactory infarcted area that is inadequate to cover the target septal zone. 5 In this case, alcohol failed to be injected into the other septal branches, and there was rich collateral circulation. After ASA, the thick septal branches on CCTA, abundant perfusion on MCE, and unsatisfactory delayed enhancement region on CMR all implied that ASA was not adequate to eliminate blood supply to the basal septum.…”

Ventricular Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy (Analysis Spanning 60 Years Of Practice): AJC Expert Panel

“…115 The vast majority of patients incur left bundle branch as a result of the operative resection which does not influence later clinical course. 112 Surgeons performing myectomy after an unsuccessful ASA report less consistent operative results and a higher rate of complete heart block, [116][117][118] underscoring that myectomy is the preferred initial procedure to avoid myocardial scarring, heart block and other potential adverse consequences of ASA.…”

Alcohol Septal Ablation in Patients with Hypertrophic Obstructive Cardiomyopathy: A Contemporary Perspective

“…CMR can be used during the follow-up to quantify the size and location of the iatrogenic infarct. The use of CMR is also helpful in the case of procedural failure to evaluate the reasons for unsuccess (i.e., the iatrogenic infarct is too small or outside the target area) [60]. In the Numerous studies have shown that approximately 90% of patients undergoing a successful procedure experience an improvement of functional status (i.e., post-procedural NYHA class I-II), and in 80% of cases, there is a significant reduction in LVOTO [53].…”

“…CMR can be used during the follow-up to quantify the size and location of the iatrogenic infarct. The use of CMR is also helpful in the case of procedural failure to evaluate the reasons for unsuccess (i.e., the iatrogenic infarct is too small or outside the target area) [60]. In the event of failure, surgical myectomy may be performed as a rescue strategy.…”

“…In the event of failure, surgical myectomy may be performed as a rescue strategy. Of note, several studies have reported on patients with a previous alcohol septal ablation undergoing surgical myectomy, showing that these patients have a higher risk of complete atrioventricular block and progression to heart failure because of the more extensive conduction system and myocardial injury [60][61][62].…”