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Septal ablation in Hypertrophic Cardiomyopathy

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Septal ablation in Hypertrophic Cardiomyopathy. Charles Knight London Chest Hospital Advanced Angioplasty 2003. Terminology. Non-surgical septal reduction (NSSR) Percutaneous transluminal septal myocardial ablation (PTSMA) Transcoronary ablation of septal hypertrophy (TASH) Septal ablation

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slide1

Septal ablation in Hypertrophic Cardiomyopathy

Charles Knight

London Chest Hospital

Advanced Angioplasty 2003

terminology
Terminology
  • Non-surgical septal reduction (NSSR)
  • Percutaneous transluminal septal myocardial ablation (PTSMA)
  • Transcoronary ablation of septal hypertrophy (TASH)
  • Septal ablation
  • Alcohol ablation
  • HOCM ablation
  • Sigwart procedure
slide3

History

  • 1980’s
  • Preliminary experiments
  • by Ulrich Sigwart at Laussane
  • Temporary balloon occlusion
  • of first septal artery
  • Injection of verapamil down
  • first septal artery
  • June 1994
  • First septal ablation by Ulrich
  • Sigwart at Royal Brompton
  • 1997
  • Described as ‘profoundly aggressive’ with an ‘unacceptably high mortality and morbidity’ in NEJM*

*NEJM 1997;337:349

patient selection
Patient selection
  • No evidence for effect on prognosis
  • Majority of patients with HCM have no obstruction (~75%)
  • Majority of patients with obstruction have symptoms responsive to medical therapy
  • Those with obstruction and unresponsive symptoms can be treated with septal ablation or myotomy-myectomy
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No effect on:

Underlying pathology

Myocardial disarray

Small coronary artery abnormalities

Diastolic dysfunction

Associated mitral valve abnormalities

Risk of sudden death

Prognosis

Effect on:

  • Outflow tract gradient
  • Symptoms
procedure
Procedure
  • Temporary pacing wire
  • Intermediate wire to S1
  • OTW balloon inflated at origin of S1
  • Wire removed, balloon inflated
  • 3-5ml of absolute alcohol injected
  • 5 minutes marination then balloon deflated
septal ablation published reports
Septal Ablation - Published Reports
  • Knight et al Circulation 1997;95:2075 18 patients
  • Faber et al Circulation 1998;98:2415 91 patients
  • Lakkis et al Circulation1998;98:1750 33 patients
  • Gietzen et al Eur Heart J 1999;20:1342 50 patients
  • Kim et al Am J Cardiol 1999;83:1220 20 patients
  • Qin et al J Am Coll Cardiol 2001;38:1994 25 patients
  • Total 237 patients

Longer term (7-36 month follow-up)

  • Gietzen et al Eur Heart J 1999;20:1342 37 patients
  • Faber et al Heart 2000;83:326 25 patients
  • Firoozi et al Eur Heart J 2002;23:1617 20 patients
  • Shamin et al NEJM 2002 ;347:1326 64 patients
  • Total 146 patients
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Pre

Post

effect on outflow gradient
Effect on Outflow Gradient
  • All reports:
    • 65 mmHg pre
    • 5 mmHg post
  • Reduction in gradient sustained in long-term

Shamin et al N Engl J Med 2002;347:1326

effect on symptoms
Effect on Symptoms
  • All reports show significant improvement
    • Mean NYHA class pre 2.85, post 1.3
  • Maintained over longer-term
effect on exercise
Effect on exercise
  • 3 reports assessed peak O2 consumption (n=104)
    • 44% improvement
  • 7 reports assessed exercise duration/watts (n=204)
    • 41% improvement
  • Maintained at longer-term

Shamin et al N Engl J Med 2002;347:1326

mortality
Mortality
  • Short-term: 5/303 deaths (1.7%)
    • 2 in patients with severe pulmonary disease
    • 1 pulmonary embolus (line-related DVT)
    • 1 sudden AV block day 4
    • 1 sudden out-of hospital (?AV block)
  • Long-term: 1 further death (pancreatic carcinoma)
heart block
Heart-Block
  • Overall rate is ~ 20% requiring PPM
  • Ranges from 0-40%
  • Incidence appears to be reducing (contrast echo)
  • 10% of surgical patients require PPM
  • Beneficial effects of procedure similar in paced/not paced patients*

*Shamin et al N Engl J Med 2002;347:1326

arrhythmias
Arrhythmias
  • Early VF in 1.6%
  • No late arrhythmias reported
slide17

Late Ventricular Dilatation

  • Information from 134 patients
  • (4 reports)
  • 4.2mm Pre
  • 4.7mm Post

Shamin et al N Engl J Med 2002;347:1326

comparison with surgery
Comparison with Surgery
  • No randomised studies
  • Two recent non-randomised comparisons
    • St George’s Hospital
    • Cleveland Clinic
  • Patients well matched but septal ablation patients older and more co-morbidity
slide19

Cleveland Clinic

St. George’s

Firoozi et al Eur Heart J 2002;23:1617

Qin et al JACC 2001;38:1994

conclusions
Conclusions
  • Still limited data
  • Not profoundly aggressive
  • Results similar to surgery
  • Mortality and morbidity acceptable and similar to surgery
  • Should be performed as part of a HCM service by experienced operators
  • Patient selection of paramount importance
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