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Survival After Septal Reduction in Patients >65 Years Old With Obstructive Hypertrophic Cardiomyopathy
Amgad Mentias1, Nicholas G Smedira1, Amar Krishnaswamy1
1Hypertrophic Cardiomyopathy Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
Insights
Septal reduction therapies (SRT) for obstructive hypertrophic cardiomyopathy (oHCM) in elderly Medicare patients reduced heart failure readmissions. Septal myectomy (SM) showed better long-term survival and lower redo rates compared to alcohol septal ablation (ASA).
Area of Science:
- Cardiology
- Interventional Cardiology
- Geriatric Medicine
Background:
- Obstructive hypertrophic cardiomyopathy (oHCM) is increasingly diagnosed in elderly populations.
- Septal reduction therapies (SRT) are treatment options for symptomatic oHCM.
Purpose of the Study:
- To evaluate long-term outcomes of septal reduction therapies (SRT) in Medicare patients with oHCM.
- To investigate the relationship between hospital volume and outcomes for SRT in oHCM patients.
Main Methods:
- Retrospective analysis of Medicare beneficiaries aged >65 years who underwent septal myectomy (SM) or alcohol septal ablation (ASA) between 2013-2019.
- Used overlap propensity score weighting to adjust for baseline differences between SM and ASA groups.
- Assessed all-cause mortality, heart failure (HF) readmission, and need for redo SRT as primary and secondary outcomes.
Main Results:
- Septal myectomy (SM) was associated with lower rates of redo SRT and improved survival after 2 years compared to alcohol septal ablation (ASA).
- Both SM and ASA reduced heart failure readmissions in the follow-up period compared to the year prior to SRT.
- Higher-volume centers demonstrated better outcomes, yet 70% of SRT procedures were performed in low-volume centers.
Conclusions:
- Septal reduction therapies (SRT) effectively reduce heart failure readmissions in elderly Medicare patients with obstructive hypertrophic cardiomyopathy (oHCM).
- Septal myectomy (SM) offers superior long-term survival and reduced need for repeat procedures compared to alcohol septal ablation (ASA).
- There is a critical disparity in care delivery, with high-volume centers showing better outcomes while most procedures occur in low-volume settings.
Background:
Obstructive hypertrophic cardiomyopathy (oHCM) is increasingly being diagnosed in elderly patients.
Objectives:
The authors sought to study long-term outcomes of septal reduction therapies (SRT) in Medicare patients with oHCM, and hospital volume-outcome relation.
Methods:
Medicare beneficiaries aged >65 years who underwent SRT, septal myectomy (SM) or alcohol septal ablation (ASA), from 2013 through 2019 were identified. Primary outcome was all-cause mortality, and secondary outcomes included heart failure (HF) readmission and need for redo SRT in follow-up. Overlap propensity score weighting was used to adjust for differences between both groups. Relation between hospital SRT volume and short-term and long-term mortality was studied.
Results:
The study included 5,679 oHCM patients (SM = 3,680 and ASA = 1,999, mean age 72.9 vs 74.8 years, women 67.2% vs 71.1%; P < 0.01). SM patients had fewer comorbidities, but after adjustment, both groups were well balanced. At 4 years (IQR: 2-6 years), although there was no difference in long-term mortality between SM and ASA (HR: 0.87; 95% CI: 0.74-1.03; P = 0.1), on landmark analysis, SM was associated with lower mortality after 2 years of follow-up (HR: 0.72; 95% CI: 0.60-0.87; P < 0.001) and had lower need for redo SRT. Both reduced HF readmissions in follow-up vs 1 year pre-SRT. Higher-volume centers had better outcomes vs lower-volume centers, but 70% of SRT were performed in low-volume centers.
Conclusions:
SRT reduced HF readmission in Medicare patients with oHCM. SM is associated with lower redo and better long-term survival compared with ASA. Despite better outcomes in high-volume centers, 70% of SRT are performed in low-volume U.S. centers.
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