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Long-term outcomes in high-risk symptomatic patients with hypertrophic cardiomyopathy undergoing alcohol septal
Deborah H Kwon1, Samir R Kapadia, E Murat Tuzcu
1Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.
Insights
Alcohol septal ablation (ASA) offers symptomatic improvement and low short-term mortality in high-risk hypertrophic obstructive cardiomyopathy (HOCM) patients. Long-term mortality is linked only to older age at the time of the procedure.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Surgical myectomy is the standard treatment for symptomatic hypertrophic obstructive cardiomyopathy (HOCM).
- Alcohol septal ablation (ASA) is reserved for high-risk HOCM patients unsuitable for surgery.
- This study evaluates ASA outcomes in a specific high-risk cohort.
Purpose of the Study:
- To assess the efficacy and safety of alcohol septal ablation (ASA).
- To evaluate outcomes in symptomatic hypertrophic obstructive cardiomyopathy (HOCM) patients at high surgical risk.
- To identify predictors of long-term mortality after ASA.
Main Methods:
- Retrospective study of 55 high-risk symptomatic HOCM patients undergoing ASA (1997-2000).
- Data collected at baseline, 3 months, and 1 year included gradients, septal thickness, quality of life (MLHFQ), and pacemaker need.
- All-cause mortality was tracked throughout the follow-up period (mean 8 years).
Main Results:
- Significant improvements observed in left ventricular outflow tract gradient, septal thickness, and MLHFQ scores at 3 months post-ASA (p < 0.001).
- Long-term mortality was predicted solely by age >65 years at the time of ASA (log-rank p = 0.03).
- 26% of patients required a new permanent pacemaker; 10-year mortality was 13 patients.
Conclusions:
- Alcohol septal ablation (ASA) provides significant symptomatic relief and is safe in the short term for high-risk HOCM patients.
- Older age (>65 years) is the primary determinant of long-term mortality following ASA.
- ASA represents a viable therapeutic option for carefully selected symptomatic HOCM patients who are poor surgical candidates.
Objectives:
We sought to assess outcomes of alcohol septal ablation (ASA) in high-risk patients.
Background:
Because surgical myectomy is the preferred treatment in patients with symptomatic hypertrophic obstructive cardiomyopathy (HOCM) at our institution, we perform ASA in patients who are at high risk for surgery.
Methods:
We studied 55 symptomatic HOCM patients (mean age 63 +/- 13 years, 67% women, mean follow-up 8 +/- 1 years), at high risk for surgery (as the result of age/comorbidities) who had ASA between 1997 and 2000. The following were recorded at baseline, 3 months, and 1 year: septal thickness, maximal (resting or provocable) left ventricular outflow tract gradient, Minnesota living with heart failure questionnaire score, and the presence of a permanent pacemaker. All-cause mortality was recorded.
Results:
No patients died at 48 h, 2 died at 1 year, 7 died at 5 years, and 13 died at 10 years. Only age >65 years at time of ASA predicted long-term mortality (log-rank p = 0.03). Mean maximal left ventricular outflow tract gradient (104 +/- 35 mm Hg vs. 49 +/- 28 mm Hg), septal thickness (2.4 +/- 0.4 cm vs. 1.8 +/- 0.6 cm), and Minnesota living with heart failure score (63 vs. 25) improved at 3 months, compared with baseline (all p < 0.001), with no significant changes at 1 year. New permanent pacemaker was present in 26% of patients.
Conclusions:
In symptomatic HOCM patients who are at high risk for surgery, ASA is associated with symptomatic improvement and low short-term mortality; with long-term mortality only associated with older age at time of procedure. In symptomatic HOCM patients at high-risk for surgery, ASA is a viable option.
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