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Outcomes of Alcohol Septal Ablation in Patients With Severe Left Ventricular Outflow Tract Obstruction: A Propensity
Josef Veselka1, Max Liebregts2, Robert Cooper3
1Department of Cardiology, Second Medical School, Charles University, University Hospital Motol, Prague, Czech Republic.
Insights
Alcohol septal ablation (ASA) is effective for hypertrophic cardiomyopathy (HCM) with high left ventricular outflow tract obstruction (LVOTO) ≥ 100 mm Hg. While survival and symptoms are similar, higher residual obstruction and reintervention rates are noted.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Current guidelines suggest alcohol septal ablation (ASA) may be less effective for hypertrophic cardiomyopathy (HCM) with left ventricular outflow tract obstruction (LVOTO) ≥ 100 mm Hg.
- This study investigates the outcomes of ASA in patients stratified by baseline LVOTO severity.
Purpose of the Study:
- To evaluate the efficacy and safety of alcohol septal ablation (ASA) in patients with hypertrophic cardiomyopathy (HCM) and high baseline left ventricular outflow tract obstruction (LVOTO) (≥ 100 mm Hg) compared to those with lower obstruction (< 100 mm Hg).
Main Methods:
- A multinational registry of 1346 ASA patients was analyzed.
- Patients were stratified based on baseline LVOTO (≥ 100 mm Hg vs < 100 mm Hg).
- Propensity score matching was used to compare long-term outcomes, including survival, LVOTO reduction, symptom burden, and reintervention rates.
Main Results:
- Patients with baseline LVOTO ≥ 100 mm Hg were older, more frequently women, and had a more pronounced HCM phenotype.
- After propensity matching, long-term survival and dyspnoea (NYHA class) were similar between groups.
- The group with higher baseline LVOTO showed a greater relative reduction in LVOTO but had higher residual LVOTO and required more reinterventions.
Conclusions:
- Alcohol septal ablation (ASA) demonstrates comparable long-term survival and symptom relief in hypertrophic cardiomyopathy (HCM) patients with high baseline left ventricular outflow tract obstruction (LVOTO) (≥ 100 mm Hg) versus those with lower obstruction.
- However, patients with higher baseline LVOTO experience greater residual obstruction and a higher likelihood of requiring repeat procedures after ASA.
Background:
The current ACC/AHA guidelines on hypertrophic cardiomyopathy (HCM) caution that alcohol septal ablation (ASA) might be less effective in patients with left ventricular outflow tract obstruction (LVOTO) ≥ 100 mm Hg.
Methods:
We used a multinational registry to evaluate the outcome of ASA patients according to baseline LVOTO.
Results:
A total of 1346 ASA patients were enrolled and followed for 5.8 ± 4.7 years (7764 patient-years). The patients with baseline LVOTO ≥ 100 mm Hg were significantly older (61 ± 14 years vs 57 ± 13 years; P < 0.01), more often women (60% vs 45%; P < 0.01), and had a more pronounced HCM phenotype than those with baseline LVOTO < 100 mm Hg. There were no significant differences in the occurrences of 30-day major cardiovascular adverse events in the 2 groups. After propensity score matching (2 groups, 257 pairs of patients), the long-term survival was similar in both groups (P = 0.10), the relative reduction of LVOTO was higher in the group with baseline LVOTO ≥ 100 mm Hg (82 ± 21% vs 73 ± 26%; P < 0.01), but the residual resting LVOTO remained higher in this group (23 ± 29 mm Hg vs 13 ± 13 mm Hg; P < 0.01). Dyspnoea (NYHA functional class) at the most recent clinical check-up was similar in the 2 groups (1.7 ± 0.7 vs 1.7 ± 0.7; P = 0.85), and patients with baseline LVOTO ≥ 100 mm Hg underwent more reinterventions (P = 0.02).
Conclusions:
After propensity matching, ASA patients with baseline LVOTO ≥ 100 mm Hg had similar survival and dyspnoea as patients with baseline LVOTO < 100 mm Hg, but their residual LVOTO and risk of repeated procedures were higher.
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