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Predicting complete heart block after alcohol septal ablation for hypertrophic cardiomyopathy using a risk
Ahmadreza Karimianpour1, Justin Heizer2, Davis Leaphart3
1Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA.
Insights
A new clinical tool can predict complete heart block (CHB) after alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM). This tool uses easily obtainable factors to identify patients at high risk for CHB.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Electrophysiology
Background:
- Alcohol septal ablation (ASA) is a key treatment for drug-refractory, symptomatic hypertrophic obstructive cardiomyopathy (HOCM).
- ASA carries a significant risk of complete heart block (CHB), ranging from 6.5% to 11%.
Purpose of the Study:
- To identify predictors of complete heart block (CHB) following alcohol septal ablation (ASA).
- To develop and validate a clinical prediction tool for stratifying CHB risk in patients undergoing ASA.
Main Methods:
- A cohort of 636 patients undergoing ASA was analyzed, with 527 used for prediction tool development and 109 for validation.
- Multivariate analysis identified key predictors, and an 11-point clinical prediction tool was created.
- The tool underwent internal and external validation using receiver operating characteristic curves and contemporary patient data.
Main Results:
- Forty-six of 527 patients developed CHB. Key predictors included age ≥50 years, pre-ASA left bundle branch block (LBBB), transient procedural block, post-ASA PR prolongation ≥68 ms, and new bifascicular block.
- The clinical prediction tool demonstrated strong internal validation (AUC=0.88).
- External validation showed 98% negative predictive value, 75% sensitivity, and 81% specificity for high-risk patients.
Conclusions:
- Complete heart block risk after ASA can be predicted using accessible clinical and electrocardiographic factors.
- A validated clinical prediction tool enables the identification of high-risk patients requiring intensified monitoring and potential therapeutic interventions.
Background:
Alcohol septal ablation (ASA) is a proven method of septal reduction for patients with drug refractory, symptomatic hypertrophic obstructive cardiomyopathy (HOCM). This procedure is associated with a 6.5-11% risk of complete heart block (CHB).
Objective:
The aim of this study is to determine factors that predict CHB and to develop a clinical tool for risk stratification of patients.
Methods:
Patients were enrolled into an ongoing ASA study. A total of 636 patient procedures were included, 527 of whom were used in the development of the prediction tool, and 109 of whom were used for independent validation. Multivariate analysis was performed with odds ratios used to develop the clinical prediction tool. This was then internally and externally validated.
Results:
Of the 527 in the prediction cohort, 46 developed CHB. The predictors of CHB were age ≥50 years, pre-ASA left bundle branch block (LBBB), transient procedural high-grade block, post-ASA PR prolongation ≥68 ms, and new bifascicular block. An 11-point clinical prediction tool was developed to classify these factors. Internal validation using a receiver operating characteristic curve revealed an area under the curve of 0.88 for the clinical prediction tool. External validation using 109 contemporary patients revealed a 98% negative predictive value, 24% positive predictive value, 75% sensitivity, and 81% specificity in high-risk patients.
Conclusion:
Among patients undergoing ASA, the risk of CHB can be predicted with easily obtained clinical and electrocardiographic factors. This clinical prediction tool allows identification of high-risk patients who may benefit from additional monitoring and therapy.
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