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Isolation and Functional Characterization of Human Ventricular Cardiomyocytes from Fresh Surgical Samples
Published on: April 21, 2014
Long-term outcomes of septal reduction for obstructive hypertrophic cardiomyopathy
Daniel Sedehi1, Gherardo Finocchiaro1, Yen Tibayan1
1Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, USA.
Insights
Surgical myectomy and alcohol septal ablation (ASA) effectively reduce left ventricular outflow tract (LVOT) gradients in hypertrophic cardiomyopathy (HCM). While both procedures improve symptoms and survival, long-term myectomy outcomes suggest a poorer prognosis for a subset of HCM patients.
Area of Science:
- Cardiology
- Cardiac Surgery
- Interventional Cardiology
Background:
- Hypertrophic cardiomyopathy (HCM) can cause significant left ventricular outflow tract (LVOT) obstruction.
- Surgical myectomy and alcohol septal ablation (ASA) are established septal reduction therapies for obstructive HCM.
- Long-term outcomes of these interventions, particularly myectomy beyond 10 years, are less understood.
Purpose of the Study:
- To evaluate the long-term efficacy and survival outcomes of surgical myectomy and ASA in patients with obstructive HCM.
- To compare the results of these procedures with general population mortality rates and historical data.
Main Methods:
- Retrospective analysis of 171 patients undergoing myectomy (1972-2006) and 52 patients undergoing ASA (for those declining surgery).
- Assessment of New York Heart Association (NYHA) functional class, echocardiographic LVOT gradients, and vital status.
- Comparison of observed mortality rates with age- and sex-matched general population data.
Main Results:
- Both myectomy and ASA significantly improved NYHA class and reduced resting and inducible LVOT gradients (p<0.001 for all).
- Myectomy survival at 20 years was 47.5%, with a standardized mortality ratio (SMR) of 1.40 (p<0.005), indicating higher mortality than the general population but favorable compared to non-operated HCM.
- ASA showed excellent short-term survival (97.8% at 2 years, 94.7% at 5 years) with an SMR comparable to the general population (0.61).
Conclusions:
- Surgical myectomy and ASA are effective septal reduction strategies for obstructive HCM, providing symptom relief and gradient reduction with favorable survival.
- While ASA survival is comparable to the general population, long-term myectomy survival, though better than historical controls, suggests a potentially poorer prognosis for surgically treated HCM patients.
- Further evaluation of newer, more extensive myectomy techniques is warranted.
Background:
Surgical myectomy and alcohol septal ablation (ASA) aim to decrease left ventricular outflow tract (LVOT) gradient in hypertrophic cardiomyopathy (HCM). Outcome of myectomy beyond 10 years has rarely been described. We describe 20 years of follow-up of surgical myectomy and 5 years of follow-up for ASA performed for obstructive HCM.
Methods:
We studied 171 patients who underwent myectomy for symptomatic LVOT obstruction between 1972 and 2006. In addition, we studied 52 patients who underwent ASA for the same indication and who declined surgery. Follow-up of New York Heart Association (NYHA) functional class, echocardiographic data, and vital status were obtained from patient records. Mortality rates were compared with expected mortality rates of age- and sex-matched populations.
Results:
Surgical myectomy improved NYHA class (2.74±0.65 to 1.54±0.74, p<0.001), reduced resting gradient (67.4±43.4mmHg to 11.2±16.4mmHg, p<0.001), and inducible LVOT gradient (98.1±34.7mmHg to 33.6±34.9mmHg, p<0.001). Similarly, ASA improved functional class (2.99±0.35 to 1.5±0.74, p<0.001), resting gradient (67.1±26.9mmHg to 23.9±29.4mmHg, p<0.001) and provoked gradient (104.4±34.9mmHg to 35.5±38.6mmHg, p<0.001). Survival after myectomy at 5, 10, 15, and 20 years of follow-up was 92.9%, 81.1%, 68.9%, and 47.5%, respectively. Of note, long-term survival after myectomy was lower than for the general population [standardized mortality ratio (SMR)=1.40, p<0.005], but still compared favorably with historical data from non-operated HCM patients. Survival after ASA at 2 and 5 years was 97.8% and 94.7%, respectively. Short-term (5 year) survival after ASA (SMR=0.61, p=0.48) was comparable to that of the general population.
Conclusion:
Long-term follow-up of septal reduction strategies in obstructive HCM reveals that surgical myectomy and ASA are effective for symptom relief and LVOT gradient reduction and are associated with favorable survival. While overall prognosis for the community HCM population is similar to the general population, the need for surgical myectomy may identify a sub-group with poorer long-term prognosis. We await long-term outcomes of more extensive myectomy approaches adopted in the past 10 years at major institutions.
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