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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Septal ablation in Hypertrophic Cardiomyopathy

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Septal ablation in hypertrophic cardiomyopathy

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


Septal ablation in hypertrophic cardiomyopathy

  • 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


Septal ablation in hypertrophic cardiomyopathy

Myotomy-myectomy


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


Septal ablation in hypertrophic cardiomyopathy

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;95:207518 patients

  • Faber et al Circulation 1998;98:241591 patients

  • Lakkis et al Circulation1998;98:175033 patients

  • Gietzen et al Eur Heart J 1999;20:134250 patients

  • Kim et al Am J Cardiol 1999;83:122020 patients

  • Qin et al J Am Coll Cardiol 2001;38:199425 patients

  • Total237 patients

Longer term (7-36 month follow-up)

  • Gietzen et al Eur Heart J 1999;20:134237 patients

  • Faber et al Heart 2000;83:32625 patients

  • Firoozi et al Eur Heart J 2002;23:161720 patients

  • Shamin et al NEJM 2002 ;347:132664 patients

  • Total146 patients


Septal ablation in hypertrophic cardiomyopathy

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


Septal ablation in hypertrophic cardiomyopathy

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


Septal ablation in hypertrophic cardiomyopathy

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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