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Septal myectomy after failed alcohol ablation: Does previous percutaneous intervention compromise outcomes of
Eduard Quintana1, Anna Sabate-Rotes2, Joseph J Maleszewski3
1Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn; Servei de Cirurgia Cardiovascular, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain.
Insights
Prior alcohol septal ablation before septal myectomy increases risks for hypertrophic obstructive cardiomyopathy patients. This includes higher rates of cardiac death, heart failure, and defibrillator use, suggesting myectomy alone is preferred.
Area of Science:
- Cardiology
- Cardiac Surgery
- Interventional Cardiology
Background:
- Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic heart muscle disease.
- Septal reduction therapy aims to relieve left ventricular outflow tract obstruction.
- Alcohol septal ablation and surgical septal myectomy are primary treatments for HOCM.
Purpose of the Study:
- To evaluate the impact of prior alcohol septal ablation on outcomes of subsequent septal myectomy in HOCM patients.
- To compare clinical and histopathological findings between patients who underwent septal myectomy after alcohol septal ablation versus primary septal myectomy.
Main Methods:
- A retrospective matched case-control study comparing 31 patients with prior alcohol septal ablation and septal myectomy to 62 control patients who underwent septal myectomy only.
- Outcomes assessed included cardiac death, advanced heart failure, implantable cardioverter-defibrillator (ICD) discharge, and surgical results.
- Preoperative echocardiography, Holter monitoring, and postoperative pathology were analyzed.
Main Results:
- Patients with prior alcohol septal ablation showed increased preoperative diastolic dysfunction, higher rates of ICD implantation (32% vs. 11%), and more arrhythmias (43% vs. 13%).
- Postoperative complete heart block was significantly higher (19.4% vs. 1.6%) in the prior ablation group, with two early deaths.
- Histopathology revealed greater interstitial and endocardial fibrosis in patients with prior alcohol septal ablation.
Conclusions:
- Prior alcohol septal ablation may increase risks for HOCM patients undergoing septal myectomy, including cardiac death, advanced heart failure, and ICD discharges.
- These findings support septal myectomy as the preferred initial treatment for septal reduction therapy in HOCM.
- Avoiding alcohol septal ablation may prevent scarring and diastolic dysfunction, leading to better long-term outcomes.
Objective:
The impact of prior alcohol septal ablation in patients who require septal myectomy for hypertrophic obstructive cardiomyopathy is unknown.
Methods:
Thirty-one patients with unsuccessful alcohol septal ablation who underwent septal myectomy were matched 1:2 to patients having had a myectomy as the only invasive procedure for hypertrophic obstructive cardiomyopathy. Study outcomes were cardiac death, advanced heart failure, and appropriate implantable cardioverter defibrillator discharge. The results of surgery, echocardiograms, and pathology specimens were compared between groups.
Results:
Patients with previous alcohol septal ablation had increased diastolic dysfunction in preoperative echocardiography, as well as more implantable cardioverter defibrillators implanted (32% vs 11%, P = .01), more arrhythmias in preoperative Holter monitoring (43% vs 13%, P = .02), and a higher incidence of postoperative complete heart block (19.4% vs 1.6%, P < .01). Two patients died early postoperatively in the prior alcohol septal ablation group, and no patients died in the primary myectomy group. One patient in each group had an implantable cardioverter defibrillator (P = .52). At a mean follow-up of 3.2 years, 7 of 31 patients and 6 of 62 patients progressed to advanced heart failure in the prior alcohol septal ablation group and the primary myectomy group, respectively (P = .1) Histopathologic analysis demonstrated greater interstitial (70% vs 26%, P < .01) and endocardial fibrosis (87% vs 67%, P = .04) in the alcohol septal ablation group.
Conclusions:
Patients with prior alcohol septal ablation undergoing surgical septal myectomy may have an increased risk of cardiac death, advanced heart failure, and implantable cardioverter defibrillator discharges. This supports septal myectomy as the preferred treatment for septal reduction therapy, avoiding scarring and diastolic dysfunction inherent to alcohol septal ablation.
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