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Abstract
With increasing awareness of the condition and particular attention being paid to family screening, the number of patients being diagnosed with hypertrophic cardiomyopathy is increasing. Although the majority of patients remain at low risk for sudden cardiac death, all patients need to undergo rigorous and ongoing risk factor stratification in order to best identify those at high risk. Although implantable cardioverter-defibrillators have proven to be effective in the prevention of sudden cardiac death, careful consideration of device implantation in high-risk patients is necessary in view of the potential for device complications and their impact on quality of life.
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Resolution of left ventricular and asymmetric septal hypertrophy after resection of left ventricular outflow obstruction in a patient with troponin-positive hypertrophic obstructive cardiomyopathy: a case report. Cardiol Young 2010; 20:580-3. [PMID: 20663266 DOI: 10.1017/s1047951110000880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report the case of a young woman with a troponin mutation of C to T nucleotide substitution in exon 17 of troponin 2 (TNNT2; c.868C.T; p.Arg288Cys) leading to hypertrophic obstructive cardiomyopathy. Following surgical resection of the outflow obstruction, she had near-complete resolution of her asymmetric left ventricular hypertrophy, such that cardiomyopathy could no longer be diagnosed on echocardiographic grounds. We believe that this unusual case shows important aspects relating to the interplay between genetic and environmental mechanisms and the overlap in the phenotypic spectrum between primary subaortic stenosis and obstructive hypertrophic cardiomyopathy.
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Synergistic effect of dual chamber pacing and disopyramide in obstructive hypertrophic cardiomyopathy. Int J Cardiol 2010; 141:195-7. [DOI: 10.1016/j.ijcard.2008.11.088] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Accepted: 11/15/2008] [Indexed: 11/22/2022]
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McKenna WJ, Kaski JP. Pacemaker therapy in hypertrophic obstructive cardiomyopathy: still awaiting the evidence. Rev Esp Cardiol 2010; 62:1217-20. [PMID: 19889331 DOI: 10.1016/s1885-5857(09)73347-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Haruki S, Minami Y, Kajimoto K, Yashiro B, Suzuki T, Kawana M, Hagiwara N. Possible acute and chronic synergistic effect of dual chamber pacing and disopyramide in obstructive hypertrophic cardiomyopathy: a case report. Eur J Heart Fail 2009; 12:94-7. [DOI: 10.1093/eurjhf/hfp166] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Shintaro Haruki
- Department of Cardiology; Tokyo Women's Medical University; 8-1, Kawada-cho Shinjuku-ku Tokyo 162-8666 Japan
| | - Yuichiro Minami
- Department of Cardiology; Tokyo Women's Medical University; 8-1, Kawada-cho Shinjuku-ku Tokyo 162-8666 Japan
| | - Katsuya Kajimoto
- Department of Cardiology; Tokyo Women's Medical University; 8-1, Kawada-cho Shinjuku-ku Tokyo 162-8666 Japan
| | - Bun Yashiro
- Department of Cardiology; Tokyo Women's Medical University; 8-1, Kawada-cho Shinjuku-ku Tokyo 162-8666 Japan
| | - Tsuyoshi Suzuki
- Department of Cardiology; Tokyo Women's Medical University; 8-1, Kawada-cho Shinjuku-ku Tokyo 162-8666 Japan
| | - Masatoshi Kawana
- Department of Cardiology; Tokyo Women's Medical University; 8-1, Kawada-cho Shinjuku-ku Tokyo 162-8666 Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology; Tokyo Women's Medical University; 8-1, Kawada-cho Shinjuku-ku Tokyo 162-8666 Japan
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Sandín M, Marín F, Cambronero F, Climent V, Caro C, Martínez JG, Honrubia AG, García Alberola A, de la Morena G, Valdés M, Sogorb F. Does pacemaker implantation provide long-term benefits in severe obstructive hypertrophic cardiomyopathy? Rev Esp Cardiol 2009; 62:1233-9. [PMID: 19889334 DOI: 10.1016/s1885-5857(09)73350-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND OBJECTIVES About 25% of patients with obstructive hypertrophic cardiomyopathy (HCM) remain symptomatic despite optimal medical treatment. Some may benefit from pacemaker implantation. The aim of this study was to determine the effect of pacemaker implantation on the left ventricular outflow tract (LVOT) gradient, the maximum thickness of the left ventricle, and functional capacity. METHODS In total, 72 patients with obstructive HCM and incapacitating symptoms underwent pacemaker implantation. Clinical examination, echocardiography (in 61 patients) and treadmill testing (in 34 patients) were performed before and after implantation. RESULTS Subjective functional capacity, as assessed using the New York Heart Association (NYHA) classification, improved in 43.1% of patients, but treadmill testing showed no change. There were significant reductions in subaortic gradient, from a median of 87.0 mmHg (interquartile range [IQR] 61.5-115.2 mmHg) to 30.0 mmHg (IQR 18.0-54.5 mmHg; P< .001), and maximum left ventricular thickness, from 22.1+/-4.5 mm to 19.8+/-3.6 mm (P=.001). Univariate analysis identified two factors associated with clinical improvement: female sex (odds ratio [OR]=3.43; P=.020) and functional class III/IV (OR=4.17; P=.009). On multivariate analysis, only functional class III/IV remained a significant predictor (OR=3.12; P=.048). CONCLUSIONS In patients with obstructive HCM and incapacitating symptoms, pacemaker implantation reduced the LVOT gradient and the maximum left ventricular thickness, but only 43.1% of patients experienced clinical improvement. The only factor predictive of improvement was advanced NYHA functional class.
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Affiliation(s)
- Míriam Sandín
- Servicio de Cardiología. Hospital General Universitario de Alicante, Alicante, España
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McKenna WJ, Kaski JP. El tratamiento con marcapasos de la miocardiopatía hipertrófica obstructiva: a la espera de la evidencia. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)73072-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Sandín M, Marín F, Cambronero F, Climent V, Caro C, Martínez JG, Honrubia AG, Alberola AG, de la Morena G, Valdés M, Sogorb F. ¿Existe un efecto beneficioso a largo plazo con el tratamiento con marcapasos de la miocardiopatía hipertrófica obstructiva severa? Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)73075-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Popov AF, Bireta C, Schmitto JD, Zenker D, Friedrich M, Coskun KO, Seipelt R, Hanekop GG, Schoendube FA. Myocardial ischemia with left ventricular outflow obstruction. J Cardiothorac Surg 2009; 4:51. [PMID: 19761610 PMCID: PMC2753314 DOI: 10.1186/1749-8090-4-51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Accepted: 09/17/2009] [Indexed: 11/10/2022] Open
Abstract
We report an unusual case of a 32-year old man who was treated for a hypertrophic obstructive cardiomyopathy (HOCM) with a DDD pacing with short AV delay reduction in the past. Without prior notice the patient developed ventricular fibrillation and an invasive cardiac diagnostic was performed, which revealed a myocardial bridging around of the left anterior descending artery (LAD). We suspected ischemia that could be either related to LAD artery compression or perfusion abnormalities due to AV delay reduction with related to diastolic dysfunction.
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Affiliation(s)
- Aron F Popov
- Department of Thoracic and Cardiovascular Surgery, University of Göttingen, Germany.
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Maron BJ, Maron MS, Wigle ED, Braunwald E. The 50-year history, controversy, and clinical implications of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy from idiopathic hypertrophic subaortic stenosis to hypertrophic cardiomyopathy: from idiopathic hypertrophic subaortic stenosis to hypertrophic cardiomyopathy. J Am Coll Cardiol 2009; 54:191-200. [PMID: 19589431 DOI: 10.1016/j.jacc.2008.11.069] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Revised: 11/12/2008] [Accepted: 11/12/2008] [Indexed: 12/17/2022]
Abstract
Dynamic obstruction to left ventricular (LV) outflow was recognized from the earliest (50 years ago) clinical descriptions of hypertrophic cardiomyopathy (HCM) and has proved to be a complex phenomenon unique in many respects, as well as arguably the most visible and well-known pathophysiologic component of this heterogeneous disease. Over the past 5 decades, the clinical significance attributable to dynamic LV outflow tract gradients in HCM has triggered a periodic and instructive debate. Nevertheless, only recently has evidence emerged from observational analyses in large patient cohorts that unequivocally supports subaortic pressure gradients (and obstruction) both as true impedance to LV outflow and independent determinants of disabling exertional symptoms and cardiovascular mortality. Furthermore, abolition of subaortic gradients by surgical myectomy (or percutaneous alcohol septal ablation) results in profound and consistent symptomatic benefit and restoration of quality of life, with myectomy providing a long-term survival similar to that observed in the general population. These findings resolve the long-festering controversy over the existence of obstruction in HCM and whether outflow gradients are clinically important elements of this complex disease. These data also underscore the important principle, particularly relevant to clinical practice, that heart failure due to LV outflow obstruction in HCM is mechanically reversible and amenable to invasive septal reduction therapy. Finally, the recent observation that the vast majority of patients with HCM have the propensity to develop outflow obstruction (either at rest or with exercise) underscores a return to the characterization of HCM in 1960 as a predominantly obstructive disease.
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Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota 55407, USA.
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62
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Pasquale F, Tomé-Esteban MT, Morgagni R, Elliott P. Provokable left ventricular outflow tract obstruction in a patient without hypertrophy. Nat Rev Cardiol 2009; 6:313-6. [PMID: 19352335 DOI: 10.1038/nrcardio.2009.7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND A 61-year-old man presented with shortness of breath and chest pain on exertion. He had been diagnosed as having hiatus hernia 2 years previously and was taking proton-pump inhibitors as necessary. He had a family history of ischemic heart disease and subarachnoid hemorrhage. INVESTIGATIONS Physical examination, electrocardiography, echocardiography, cardiopulmonary exercise testing, coronary angiography, transoesophageal echocardiography, stress echocardiography. DIAGNOSIS Provokable left ventricular outflow tract obstruction without electrocardiographic abnormalities or left ventricular hypertrophy on echocardiography. MANAGEMENT Pharmacological therapy (atenolol 50 mg daily, disopyramide 250 mg twice daily), dual-chamber pacemaker implantation.
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63
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Silvestry FE, Kerber RE, Brook MM, Carroll JD, Eberman KM, Goldstein SA, Herrmann HC, Homma S, Mehran R, Packer DL, Parisi AF, Pulerwitz T, Seward JB, Tsang TSM, Wood MA. Echocardiography-guided interventions. J Am Soc Echocardiogr 2009; 22:213-31; quiz 316-7. [PMID: 19258174 DOI: 10.1016/j.echo.2008.12.013] [Citation(s) in RCA: 170] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A major advantage of echocardiography over other advanced imaging modalities (magnetic resonance imaging, computed tomographic angiography) is that echocardiography is mobile and real time. Echocardiograms can be recorded at the bedside, in the cardiac catheterization laboratory, in the cardiovascular intensive care unit, in the emergency room-indeed, any place that can accommodate a wheeled cart. This tremendous advantage allows for the performance of imaging immediately before, during, and after various procedures involving interventions. The purpose of this report is to review the use of echocardiography to guide interventions. We provide information on the selection of patients for interventions, monitoring during the performance of interventions, and assessing the effects of interventions after their completion. In this document, we address the use of echocardiography in commonly performed procedures: transatrial septal catheterization, pericardiocentesis, myocardial biopsy, percutaneous transvenous balloon valvuloplasty, catheter closure of atrial septal defects (ASDs) and patent foramen ovale (PFO), alcohol septal ablation for hypertrophic cardiomyopathy, and cardiac electrophysiology. A concluding section addresses interventions that are presently investigational but are likely to enter the realm of practice in the very near future: complex mitral valve repairs, left atrial appendage (LAA) occlusion devices, 3-dimensional (3D) echocardiographic guidance, and percutaneous aortic valve replacement. The use of echocardiography to select and guide cardiac resynchronization therapy has recently been addressed in a separate document published by the American Society of Echocardiography and is not further discussed in this document. The use of imaging techniques to guide even well-established procedures enhances the efficiency and safety of these procedures.
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Affiliation(s)
- Frank E Silvestry
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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64
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Benditt DG, Nguyen JT. Syncope. J Am Coll Cardiol 2009; 53:1741-51. [DOI: 10.1016/j.jacc.2008.12.065] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Revised: 12/01/2008] [Accepted: 12/15/2008] [Indexed: 10/20/2022]
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Soon CY, Buergler JM. Alcohol septal ablation and the Brockenbrough-Braunwald phenomenon. Catheter Cardiovasc Interv 2009; 72:1016-24. [PMID: 19021274 DOI: 10.1002/ccd.21766] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Chao Y Soon
- Methodist DeBakey Cardiology Associates, 6550 Fannin Street, Suite 1901, Houston, Texas 77030, USA
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66
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Amit G, Quan KJ. Cardiac Pacemakers – Past, Present, and Future. Neuromodulation 2009. [DOI: 10.1016/b978-0-12-374248-3.00067-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rhee EK, Nigro JJ, Pophal SG. Therapeutic options in hypertrophic cardiomyopathy: A pediatric perspective. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2008; 10:433-41. [DOI: 10.1007/s11936-008-0035-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Graham-Cryan MA, Rowe G, Hathaway L, Biddle S, Tripodi D, Fananapazir L. Obstructive Hypertrophic Cardiomyopathy. ACTA ACUST UNITED AC 2008; 19:133-40. [PMID: 15539974 DOI: 10.1111/j.0889-7204.2003.03400.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hypertrophic cardiomyopathy (HCM) is a primary disease of cardiac muscle characterized by a thickening of the left ventricular wall and often predominantly affecting the interventricular septum. This paper presents a case study of a 53-year-old female with a dynamic and obstructive form of HCM. The study includes a case presentation, clinical findings, investigations, and management. Patient findings were obtained before and after alcohol septal ablation, a novel interventional therapy. The article reviews the various forms of HCM and describes the currently available treatment modalities for obstructive HCM. Further research will be necessary to determine the comparative efficacy between past, present, and future therapies.
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Affiliation(s)
- Melissa A Graham-Cryan
- Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, 10 Center Drive MSC 1650, Room 7B-15, Bethesda, MD 20892-1650, USA.
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Brown ML, Schaff HV. Surgical management of obstructive hypertrophic cardiomyopathy: the gold standard. Expert Rev Cardiovasc Ther 2008; 6:715-22. [PMID: 18510487 DOI: 10.1586/14779072.6.5.715] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
While medication is the first line of therapy in obstructive hypertrophic cardiomyopathy, patients who have symptoms refractory to medical treatment or asymptomatic patients with high resting gradients (>or=30 mmHg) may require septal myectomy. Surgical septal myectomy can be performed safely, with excellent survival, relief from symptoms and low morbidity. Alcohol septal ablation is an alternative to surgical treatment, but late outcomes are uncertain. Although both methods of septal reduction relieve left ventricular outflow tract gradients and improve functional status, the need for permanent pacing appears higher with alcohol ablation compared with surgical myectomy. As our understanding of obstructive hypertrophic cardiomyopathy continues to grow, the indications for intervention will evolve. In our practice, septal myectomy remains the gold standard for treatment of obstructive hypertrophic cardiomyopathy.
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Affiliation(s)
- Morgan L Brown
- Division of Cardiovascular Surgery, 200 1st St SW, Rochester, MN 55905, USA.
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Clinical and Echocardiographic Variables Fail to Predict Response to Dual-Chamber Pacing for Hypertrophic Cardiomyopathy. J Am Soc Echocardiogr 2008; 21:796-800. [DOI: 10.1016/j.echo.2007.11.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2007] [Indexed: 11/24/2022]
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Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Smith SC, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Faxon DP, Halperin JL, Hiratzka LF, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 51:e1-62. [PMID: 18498951 DOI: 10.1016/j.jacc.2008.02.032] [Citation(s) in RCA: 1101] [Impact Index Per Article: 68.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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72
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ACC/AHA/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities. Heart Rhythm 2008; 5:e1-62. [PMID: 18534360 DOI: 10.1016/j.hrthm.2008.04.014] [Citation(s) in RCA: 196] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Indexed: 01/27/2023]
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73
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Epstein AE, Dimarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: executive summary. Heart Rhythm 2008; 5:934-55. [PMID: 18534377 DOI: 10.1016/j.hrthm.2008.04.015] [Citation(s) in RCA: 267] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Indexed: 11/16/2022]
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Johansson B, Mörner S, Waldenström A, Stål P. Myocardial capillary supply is limited in hypertrophic cardiomyopathy: A morphological analysis. Int J Cardiol 2008; 126:252-7. [PMID: 17532066 DOI: 10.1016/j.ijcard.2007.04.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 04/10/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To clarify the morphological basis of the limited coronary reserve in hypertrophic cardiomyopathy (HCM). BACKGROUND Some of the symptoms in Hypertrophic cardiomyopathy (HCM), such as chest pain, dyspnea and arrhythmia, may be explained by myocardial ischemia. Many patients with HCM are known to exhibit these symptoms in the absence of atherosclerosis in the major coronary vessels. Decreased myocardial perfusion has been demonstrated in HCM, however, little is known about the myocardial capillary morphology in this disease. METHODS Using immunohistochemistry and morphometry, we analysed capillaries and cardiomyocytes in myectomy specimens from 5 patients with HCM with moderate hypertrophy and left ventricular outflow tract obstruction and in 5 control hearts. RESULTS The number of capillaries per cardiomyocyte (p<0.009) and number of capillaries per cardiomyocyte area unit, reflecting cardiomyocyte mass (p=0.009), were lower in individuals with HCM, i.e. indicating loss of capillaries. In HCM, the capillary density was 33% lower (p<0.05). CONCLUSIONS Our morphologic findings show that the capillary supply, and thus the coronary reserve, is impaired in HCM with moderate hypertrophy and left ventricular outflow tract obstruction. These data may partly explain the limitation of myocardial perfusion in HCM, which is associated with worse prognosis. Furthermore, we present evidence of actual loss of myocardial capillaries in HCM and a defective capillary growth.
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Affiliation(s)
- Bengt Johansson
- Department of Integrative Medical Biology, Anatomy, Umeå University, SE-90187 Umeå, Sweden.
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[Evolution of the surgical strategy in hypertrophic cardiomyopathy: case studies of eight patients]. Ann Cardiol Angeiol (Paris) 2007; 57:16-21. [PMID: 18054343 DOI: 10.1016/j.ancard.2007.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2005] [Accepted: 08/27/2007] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Hypertrophic cardiomyopathy is an inherited disease characterized by a left ventricular hypertrophy, a diastolic dysfunction and rhythm troubles with risk of sudden death. There was an evolution in the surgical strategy to treat the patients who present a left ventricular outflow tract gradient. MATERIALS AND METHODS A retrospective study was conducted: We selected eight cases who presented an hypertrophic cardiomyopathy and operated on. Pre and post operative echocardiographic data were analysed. Follow up was obtained by call or mail to the cardiologist. RESULTS The patients were classified in four groups: isolated left ventricular outflow tract obstruction, left ventricular outflow tract obstruction and associated lesions, obstructive hypertrophic cardiomyopathy and endocarditis, post operative complications of the hypertrophic cardiomyopathy surgery. We observed a significant decrease of the left ventricular outflow tract mean gradient in the post operative period and at four years. CONCLUSION Surgical management of obstructive hypertrophic cardiomyopathy remain an important option in young patients, in case of failure of the ethanol septal ablation or in patients who present other surgical lesions. The dual chamber stimulation remain indicated in old patients.
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Lenarczyk R, Kowalski O, Kukulski T, Kowalczyk J, Kalarus Z. Resynchronization or dyssynchronization--successful treatment with biventricular stimulation of a child with obstructive hypertrophic cardiomyopathy without dyssynchrony. J Cardiovasc Electrophysiol 2007; 18:542-4. [PMID: 17456135 DOI: 10.1111/j.1540-8167.2007.00763.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We present a case of a 10-year-old boy with hypertrophic cardiomyopathy, intraventricular pressure gradient of 104 mmHg, and indications for prophylactic ICD implantation. Based on intraoperative pressure measurements, the child was implanted with biventricular ICD. During 2.5 months of observation, the patient's functional status improved significantly, as shown by subjective and objective parameters and, moreover, the pressure gradient fell to 12 mmHg. Significant electrical and mechanical cardiac dyssynchrony appeared parallel to clinical improvement.
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Affiliation(s)
- Radoslaw Lenarczyk
- First Department of Cardiology, Silesian Medical School, Silesian Center for Heart Diseases, Zabrze, Poland.
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81
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Llamas-Esperón GA, Sandoval-Navarrete S. Percutaneous septal ablation with absorbable gelatin sponge in hypertrophic obstructive cardiomyopathy. Catheter Cardiovasc Interv 2007; 69:231-5. [PMID: 17195195 DOI: 10.1002/ccd.20935] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The treatment of the hypertrophic obstructive cardiomyopathy (HOCM) by percutaneous transluminal septal myocardial ablation (PTSMA) with ethanol injection has greatly improved in the last years. This report describes the case of a patient with symptomatic drug-refractory HOCM who underwent an unsuccessful attempt to thrombose the septal artery by PTSMA with alcohol. It has therefore been decided to use small absorbant gelatin sponge (AGS) particles, obtaining immediate thrombotic occlusion of the artery and excellent hemodynamic results with immediate and permanent disappearance of the gradient. The patient progressed satisfactorily and displayed lower than average creatine kinase levels in comparison to the rest of our PTMSA patients. After 2 years of follow-up he still remains asymptomatic and without any gradient. These results suggest that PTSMA with AGS could be a valuable alternative treatment of HOCM.
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82
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Sud S, Massel D, Klein GJ, Leong-Sit P, Yee R, Skanes AC, Gula LJ, Krahn AD. The expectation effect and cardiac pacing for refractory vasovagal syncope. Am J Med 2007; 120:54-62. [PMID: 17208080 DOI: 10.1016/j.amjmed.2006.05.046] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Revised: 04/18/2006] [Accepted: 05/13/2006] [Indexed: 01/31/2023]
Abstract
BACKGROUND Clinical trials of pacing for vasovagal syncope have shown conflicting results. We performed a meta-analysis to determine whether permanent pacemaker therapy prevents refractory vasovagal syncope. METHODS Randomized trials comparing pacemaker therapy with medical therapy, usual care, placebo, or different pacing algorithms in the prevention of recurrent vasovagal syncope were considered. The primary endpoint was first recurrence of syncope. RESULTS Nine randomized trials (2 double blind, 7 open label or single blind) were included. There was significant heterogeneity when all 9 trials were pooled (P=.0009 and I(2)=69.6%), reflecting methodological diversity in blinding and the nature of the control therapy. When pooled by trial methodology, heterogeneity was no longer apparent. Permanent pacing reduced the risk of recurrent syncope in unblinded studies (odds ratio [OR] 0.09, 95% confidence interval [CI], 0.04 to 0.22) and in studies comparing pacemaker algorithms (OR 0.04, 95% CI, 0.0 to 0.23). No effect was seen in double-blinded trials (OR 0.83, 95% CI, 0.41 to 1.70). Awareness that a permanent pacemaker was implanted and functional was associated with a significant 'expectation' effect, which itself reduced the risk of recurrent syncope (OR 0.16, 95% CI, 0.06 to 0.40, P=.0001). Results were similar when restricted to patients with a marked cardioinhibitory response on baseline tilt table testing. CONCLUSION The results of small, preliminary trials have overestimated the treatment effect of pacemakers due to a lack of blinding of physicians and patients. Blinded trials suggest that the apparent response is due to a strong expectation response to pacing.
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Affiliation(s)
- Sachin Sud
- Division of Cardiology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
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83
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Nielsen CD, Killip D, Spencer WH. Nonsurgical septal reduction therapy for hypertrophic obstructive cardiomyopathy: short-term results in 50 consecutive procedures. Clin Cardiol 2006; 26:275-9. [PMID: 12839045 PMCID: PMC6654060 DOI: 10.1002/clc.4950260607] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Nonsurgical septal reduction therapy (NSRT) has been shown to improve left ventricular outflow tract (LVOT) gradients, decrease septal thickness, and improve symptoms in patients with hypertrophic obstructive cardiomyopathy (HOCM). The major complication of this procedure has been the development of complete heart block (CHB) requiring permanent pacemaker implantation, which has been reported in up to 33% of patients in early studies. Since this procedure was first reported, there have been refinements in the technique such as the use of echocardiographic contrast material to localize the site of infarction, slower injection of alcohol, as well as improvement in balloon technology. HYPOTHESIS We sought to determine the results of NSRT using echocardiographic contrast localization, slow injection of alcohol, and short balloon length. We theorized that the incidence CHB would be lower than earlier reported results using these refined techniques. METHODS We performed 50 NSRT procedures on 46 patients using echocardiographic contrast localization, slow alcohol injection, and currently available balloons. Patients had an echocardiogram before, immediately after NSRT, and at 3 months, and a treadmill test before and at 3 months after NSRT. In the hospital, patients were observed for the development of CHB or other complications, and infarct size was determined by serial creatine kinase (CK) measurements. RESULTS There was a decrease in the LVOT gradient from 84.2 (+/- 30.8) mmHg at baseline, to 18.5 (+/- 14.8) mmHg immediately after NSRT (p < 0.001). At 3 months, the gradient was not statistically different at 22.7 (+/- 22.2) mmHg 0.27). The septal thickness decreased from 2.21 (+/- 0.66) cm at baseline, to 1.67 (+/- 0.51) cm at 3 months (p < 0.001). New York Heart Association symptom class improved from 3.2 (+/- 0.4) at baseline, to 1.1 (+/- 0.6) at 3 months (p < 0.001). Mean treadmill time in 30 patients was 235 (+/- 142) s at baseline, to 367 (+/- 159) s at 3 months (p < 0.001). Of the 50 procedures, 45 were performed in patients without a previously placed permanent pacemaker or intracardiac cardioverter defibrillator, only 3 (6.7%) of the 45 developed complete heart blocks required permanent pacing. While only three patients in the series had a preexisting left bundle-branch block (LBBB), two of the three patients who required a permanent pacemaker had an LBBB before the prcoedure. CONCLUSION Using contrast echocardiographic localization, slow injection of alcohol, and shorter balloon catheters, there continues to be excellent improvement in LVOT gradients, septal thickness, and symptoms, with a reduced incidence of CHB requiring permanent pacemaker implantation. Left bundle-branch block appears to be a strong predictor for the development of CHB after NSRT.
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Affiliation(s)
- Christopher D Nielsen
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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84
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Delgado V, Sitges M, Andrea R, Rivera S, Masotti M, Francino A, Azqueta M, Paré C, Betriu A. Seguimiento clínico y ecocardiográfico de pacientes con miocardiopatía hipertrófica obstructiva tratados con ablación septal percutánea. Rev Esp Cardiol 2006. [DOI: 10.1157/13095781] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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85
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Abstract
Implantable cardiac devices have become firmly entrenched as important therapeutic tools for a variety of cardiac conditions. The first part of this two-part review will discuss the contemporary use and follow-up of pacemakers, while the second part will address the use of implantable cardioverter defibrillators and implantable loop recorders. Pacemakers are the only available treatment for symptomatic bradycardia not due to reversible causes. Large randomized studies have demonstrated a small but statistically significant reduction in atrial fibrillation associated with pacing modes that maintain atrioventricular synchrony. In contrast, pacing mode appears to have a less dramatic effect in patients with atrioventricular block. Cardiac resynchronization with specialized left ventricular leads has been shown to reduce symptoms and improve survival in patients with symptomatic heart failure, systolic dysfunction, and widened QRS complexes. For all patients, careful follow-up is necessary to ensure optimal therapeutic benefit of pacing systems.
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Affiliation(s)
- Fred M Kusumoto
- Electrophysiology and Pacing Service, Division of Cardiology, Department of Medicine, Mayo Clinic, Jacksonville, Florida 32224, USA.
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86
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Abstract
All patients with hypertrophic cardiomyopathy (HCM) should have five aspects of care addressed. An attempt should be made to detect the presence or absence of risk factors for sudden arrhythmic death. If the patient appears to be at high risk, discussion of the benefits and risks of ICD are indicated, and many such patients will be implanted. Symptoms are appraised and treated. Bacterial endocarditis prophylaxis is recommended. Patients are advised to avoid athletic competition and extremes of physical exertion. First degree family members should be screened with echocardiography and ECG.
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Affiliation(s)
- Mark V Sherrid
- Hypertrophic Cardiomyopathy Program and Echocardiography Laboratory, Department of Medicine, Division of Cardiology, St. Luke's-Roosevelt Hospital Center, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
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87
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Topilski I, Sherez J, Keren G, Copperman I. Long-term effects of dual-chamber pacing with periodic echocardiographic evaluation of optimal atrioventricular delay in patients with hypertrophic cardiomyopathy >50 years of age. Am J Cardiol 2006; 97:1769-75. [PMID: 16765132 DOI: 10.1016/j.amjcard.2006.01.040] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2005] [Revised: 01/02/2006] [Accepted: 01/02/2006] [Indexed: 11/23/2022]
Abstract
Various treatment modalities have been introduced to reduce the subaortic pressure gradient in patients with obstructive hypertrophic cardiomyopathy, including pacemaker insertion. Complete ventricular capture during pacing is essential and requires optimization of the atrioventricular interval (AVI). In this study, a protocol using echocardiographic examination assessing the changes in the left ventricular outflow tract (LVOT) gradient in different AVIs, pacing rates, and pacing modes was used for optimal pacemaker programming. Twenty-five patients with obstructive hypertrophic cardiomyopathy were implanted with DDD pacemakers and evaluated prospectively. The LVOT gradient was measured during periodic evaluations every 3 to 6 months. Gradient measurements were done with 5 different AVIs and 3 different rate combinations. After each evaluation, the optimal AVI, pacing rate, and mode were set on the basis of the minimal LVOT gradient not associated with systolic arterial cuff pressure reduction. Follow-up ranged from 18 to 126 months. Peak LVOT gradient immediately decreased in 92% of patients. During follow-up, the optimal AVI was prolonged in most patients. Sixty-four percent of patients showed a clear relation between pacemaker modifications and gradient reduction. In 75% of these patients, optimal gradient reduction required repeated AVI and pacing rate programming on the basis of echocardiographic evaluation. Symptoms decreased in 92% of patients, and New York Heart Association class improved significantly (3.1+/-0.7 vs 1.3+/-0.4, p<0.001) during follow-up. The symptomatic reduction was positively correlated with the LVOT gradient reduction. In conclusion, DDD pacing is effective in reducing the LVOT gradient and improving functional capacity in adult patients with hypertrophic cardiomyopathy. Pacemaker programming with the periodic echocardiographic evaluation of the optimal AVI, pacing rate, and mode is imperative for optimal results.
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Affiliation(s)
- Ian Topilski
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.
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88
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Kataoka H. Pacemaker-induced mitral regurgitation as a cause of refractory congestive heart failure during pacing therapy in a patient with hypertrophic obstructive cardiomyopathy. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2006; 12:112-5. [PMID: 16596049 DOI: 10.1111/j.1527-5299.2006.04768.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
This report describes a woman with hypertrophic obstructive cardiomyopathy in whom initial hemodynamic improvement by dual chamber (DDD) pacing with short atrioventricular delay was excellent, but severe mitral regurgitation developed during the subsequent follow-up period, resulting in refractory congestive heart failure. There were two possible explanations for the origin of the complicating mitral regurgitation in this patient: pacing-induced semiclosure of the mitral valve, or left ventricular asynchrony caused by right ventricular pacing. Heart failure in patients with hypertrophic obstructive cardiomyopathy who undergo placement of a DDD pacemaker to improve not only mitral regurgitation but also heart failure symptoms can be associated with systolic mitral regurgitation as the cause of failure in DDD pacing therapy.
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89
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Hozumi T, Ito T, Suwa M, Sakai Y, Kitaura Y. Effects of dual-chamber pacing on regional myocardial deformation in patients with hypertrophic obstructive cardiomyopathy. Circ J 2005; 70:63-8. [PMID: 16377926 DOI: 10.1253/circj.70.63] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This study examined the effects of dual-chamber pacing (DDD) on regional myocardial deformation, as determined by echocardiographic strain and strain rate (SR) imaging, in patients with hypertrophic obstructive cardiomyopathy (HOCM). METHODS AND RESULTS Fourteen patients (11 men, 3 women; mean age 55 +/-16 years) who had been on long-term DDD (mean period 7.4 +/- 2.1 years) underwent strain and SR imaging. Before and after DDD, the peak strain (%) and SR (s(-1)) during systole were assessed in 8 segments in 4 left ventricular (LV) walls. With DDD turned on, peak strain and SR were significantly increased in the basal anteroseptal (strain -10.2 +/- 6.8 to -1.0 +/- 6.4, p<0.005; SR -0.76 +/- 0.46 to 0.05 +/- 0.58, p<0.001) and septal segments (strain -11.2 +/- 8.9 to -2.2 +/- 7.7, p<0.005; SR -0.85 +/- 0.54 to -0.19 +/- 0.75, p<0.05), but not in the basal posterior (strain -15.0 +/- 13.0 to -13.4 +/- 9.2, p=NS; SR -1.37 +/- 0.57 to -1.93 +/- 0.65, p=NS) and lateral segments (strain -18.1 +/- 10.2 to -15.7 +/- 5.6, p=NS; SR -1.33 +/- 0.68 to -0.84 +/- 0.88, p=NS). These findings were associated with a modest, but significant, change in the LV pressure gradient (24 +/- 12 mmHg to 14 +/- 7 mmHg, p<0.001). CONCLUSIONS In patients with HOCM, DDD appeared to produce myocardial lengthening in the basal septum during systole, which may have implications for the mechanism of reducing LV outflow obstruction during DDD.
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Affiliation(s)
- Tomomi Hozumi
- Third Division, Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan
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90
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Ito T, Suwa M, Sakai Y, Hozumi T, Kitaura Y. Usefulness of tissue Doppler imaging for demonstrating altered septal contraction sequence during dual-chamber pacing in obstructive hypertrophic cardiomyopathy. Am J Cardiol 2005; 96:1558-62. [PMID: 16310440 DOI: 10.1016/j.amjcard.2005.07.073] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2005] [Revised: 07/06/2005] [Accepted: 07/06/2005] [Indexed: 11/24/2022]
Abstract
Dual-chamber pacing reduces left ventricular (LV) outflow obstruction in patients with obstructive hypertrophic cardiomyopathy (HC), the mechanism of which lies in pacing-induced paradoxic septal motion. This study was conducted to test the hypothesis that tissue Doppler imaging (TDI) could demonstrate changes in the septal contraction sequence during dual-chamber pacing in patients with HC. TDI was performed in 16 patients (5 women; mean age 63+/-11 years) who underwent dual-chamber pacing for 7.6+/-2.1 year. With and without pacing, the time to peak systolic myocardial velocity was measured from the basal, mid, and distal segments in the 4 different LV walls. Without pacing, there was almost no longitudinal segmental asynchrony. During pacing, however, marked longitudinal segmental asynchrony appeared, especially in the anteroseptal wall (from p=NS to p<0.01 by analysis of variance) and the ventricular septum (from p<0.05 to p<0.01), with the time to peak velocity extremely prolonged at the distal segments. This was associated with a modest but significant decrease in the LV pressure gradient (from 20+/-8 to 14+/-7 mm Hg, p<0.01). In patients with obstructive HC, altered septal contraction sequence accounts for the reduced LV outflow obstruction during dual-chamber pacing, which was clearly demonstrated by TDI.
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Affiliation(s)
- Takahide Ito
- The Third Division, Department of Internal Medicine, Osaka Medical College, Takatsuki, Osaka, Japan.
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91
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Fernandes VL, Nagueh SF, Franklin J, Wang W, Roberts R, Spencer WH. A prospective follow-up of alcohol septal ablation for symptomatic hypertrophic obstructive cardiomyopathy--the Baylor experience (1996-2002). Clin Cardiol 2005; 28:124-30. [PMID: 15813618 PMCID: PMC6654248 DOI: 10.1002/clc.4960280305] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND There is a paucity of data on the long-term outcome of alcohol septal ablation (ASA) for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). HYPOTHESIS The study was undertaken to evaluate the longer-term outcome of ASA therapy for symptomatic HOCM. METHODS In all, 137 patients were enrolled consecutively (1996-1999) and 130 (95%) (74 men, 56 women, aged 51 +/- 17 years) underwent ASA and had serial prospective follow-up for up to 5 years (mean follow-up 3.6 +/- 1.4 years). Evaluation included angina (Canadian Cardiovascular Society [CCS] score), dyspnea (New York Heart Association [NYHA] class), duration of exercise on treadmill, and echocardiographic indices. RESULTS Ethanol (3.5 +/- 1.5 cc), injected into 1.5 +/- 0.6 arteries, induced a mean peak plasma creatine kinase (CK) of 1676 +/- 944 units. Complications of procedures included death 1.5% (2/130), heart block requiring permanent pacemaker 13% (17/130), and coronary dissection 4.4% (6/130). Baseline versus last follow-up visit: NYHA class decreased from 3.0 +/- 0.4 to 1.2 +/- 0.6 (p < 0.01); CCS angina score from 2.0 +/- 0.8 to 0.08 +/- 0.4 (p < 0.01); and duration of exercise increased from 322 +/- 207 to 443 +/- 200 s (p < 0.01). Resting left ventricular outflow tract gradient at baseline versus last follow-up visit showed a decrease from 74 +/- 30 to 4 +/- 13 (p < 0.01), and the dobutamine-provoked gradient of 88 +/- 29 decreased to 21 +/- 21 (p < 0.01) mmHg. All-cause mortality over the duration of follow-up was 7.7% (10) giving an annual rate of 2.1%, and cardiac mortality was 2.3% (3) reflecting an annual rate of 0.6%. CONCLUSIONS Alcohol septal ablation decreased symptoms and improved exercise performance, indicating that it is an effective procedure for symptomatic HOCM.
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Affiliation(s)
- Valerian L. Fernandes
- Section of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Sherif F. Nagueh
- Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer Franklin
- Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Wei Wang
- Section of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Robert Roberts
- Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - William H. Spencer
- Section of Cardiology, Medical University of South Carolina, Charleston, South Carolina
- Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
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93
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Megevand A, Ingles J, Richmond DR, Semsarian C. Long-term follow-up of patients with obstructive hypertrophic cardiomyopathy treated with dual-chamber pacing. Am J Cardiol 2005; 95:991-3. [PMID: 15820173 DOI: 10.1016/j.amjcard.2004.12.045] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2004] [Revised: 12/16/2004] [Accepted: 12/16/2004] [Indexed: 11/30/2022]
Abstract
In this study, patients with obstructive hypertrophic cardiomyopathy (HC) were treated with dual-chamber pacemaker therapy. Long-term follow-up analysis showed that dual-chamber pacemaker therapy in selected patients resulted in a significant reduction in symptoms and in the left ventricular outflow tract gradient, which was maintained up to 10 years after implantation. Dual-chamber pacing is of potential long-term benefit in selected groups of patients with obstructive HC.
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Affiliation(s)
- Angelique Megevand
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
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94
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Honda T, Shono H, Koyama J, Tsuchiya T, Hayashi M, Hirayama T, Uesugi H, Honda T. Impact of Right Atrial-Left Ventricular Dual-Chamber Permanent Pacing in Patients With Severely Symptomatic Hypertrophic Obstructive Cardiomyopathy. Circ J 2005; 69:536-42. [PMID: 15849439 DOI: 10.1253/circj.69.536] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Effective alternatives to surgical myectomy for patients with symptomatic hypertrophic obstructive cardiomyopathy (HOCM) remain unestablished. Dual-chamber (DDD) pacing was evaluated in these patients using right atrial (RA) and epicardial left ventricular (LV) leads. METHODS AND RESULTS In 6 patients with HOCM refractory to medical therapy and conventional RA-right ventricular (RV) DDD pacing, we implanted DDD pacemakers using RA and epicardial LV leads. The baseline intraventricular pressure gradient before pacemaker implantation was 103+/-44 mmHg. The pressure gradient decreased significantly to 8+/-16 mmHg by temporary RA-LV DDD pacing (p=0.006), while it decreased only to 68+/-25 mmHg by temporary RA-RV pacing (NS). It was nearly eliminated to 1+/-2 mmHg (p=0.027) 3 months after RA-LV DDD pacemaker implantation. LV end-diastolic pressure, cardiac index and systolic aortic pressure did not change significantly. New York Heart Association class improved in all patients (p=0.023). Brain and atrial natriuretic peptide concentrations, respectively 516+/-286 and 143+/-34 pg/ml at baseline, decreased significantly to 230+/-151 and 93+/-44 pg/ml 3 months after implantation (p=0.027 and 0.028). CONCLUSION RA-LV DDD pacemaker implantation is a useful option for patients with symptomatic HOCM.
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Affiliation(s)
- Toshihiro Honda
- Division of Cardiology, Cardiovascular Center, Saiseikai Kumamoto Hospital, Japan.
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95
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The case for surgery in obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol 2004; 44:2044-53. [PMID: 15542290 DOI: 10.1016/j.jacc.2004.04.063] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2003] [Accepted: 04/27/2004] [Indexed: 12/28/2022]
Abstract
Relief of left ventricular (LV) outflow obstruction in patients with hypertrophic cardiomyopathy (HCM) and disabling symptoms refractory to maximum medical management has historically been a surgical problem. Surgical septal myectomy permanently abolishes systolic anterior motion of the mitral valve and mitral regurgitation, while normalizing LV pressures and wall stress. Also, these salutary goals are achieved without encumbering patients with post-procedural devices (e.g., pacemakers or defibrillators) or creating potentially arrhythmogenic substrates, as may occur with alcohol septal ablation. Procedural morbidity and mortality risk with myectomy is similar to, and in some institutions less than those for alcohol septal ablation. Over four decades, reports from numerous centers worldwide have consistently and unequivocably documented the benefits of surgery on hemodynamic and functional state, restoring normal and acceptable quality of life to patients of all ages by largely reversing the complications of heart failure. Long-term survival after myectomy is similar to that of the general population and superior to non-operated patients with obstruction. The LV outflow tract morphology in HCM is heterogeneous and not uncommonly includes congenital anomalies of the mitral valve apparatus for which the surgeon has the flexibility to adapt the repair, often employing an extended myectomy. In the current atmosphere of increasing and perhaps excessive enthusiasm for newer catheter-based interventions, it is a critical time to promote and re-emphasize that surgery is the time-honored (and presently the most effective) treatment strategy for relieving heart failure-related disability resulting from dynamic LV outflow obstruction in HCM, and is the primary treatment option for this subgroup of severely symptomatic drug-refractory patients.
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96
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Abstract
Permanent cardiac pacing remains the only effective treatment for chronic, symptomatic bradycardia. In recent years, the role of implantable pacing devices has expanded substantially. At the beginning of the 21st century, exciting developments in technology seem to happen at an exponential rate. Major advances have extended the use of pacing beyond the arrhythmia horizon. Such developments include dual-chamber pacers, rate-response algorithms, improved functionality of implantable cardioverter defibrillators, combinations of sensors for optimum physiological response, and advances in lead placement and extraction. Cardiac pacing is poised to help millions of patients worldwide to live better electrically. We review pacing studies of sick-sinus syndrome, neurocardiogenic syncope, hypertrophic obstructive cardiomyopathy, and cardiac resynchronisation therapy, which are common or controversial indications for cardiac pacing. We also look at the benefits and complications of implantation in specific arrhythmias, suitability of different pacing modes, and the role of permanent pacing in the management of patients with heart failure.
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Affiliation(s)
- Richard G Trohman
- Department of Medicine, Section of Cardiology, Electrophysiology, Arrhythmia, and Pacemaker Service, Rush-Presbyterian-St Luke's Medical Centre and Rush Medical College, Chicago, IL 60612, USA.
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97
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Dimitrow PP, Podolec P, Grodecki J, Płazak W, Dudek D, Pieniazek P, Bacior B, Legutko J, Olszowska M, Kostkiewicz M, Kawecka-Jaszcz K, Tracz W, Dubiel JS. Comparison of dual-chamber pacing with nonsurgical septal reduction effect in patients with hypertrophic obstructive cardiomyopathy. Int J Cardiol 2004; 94:31-4. [PMID: 14996471 DOI: 10.1016/j.ijcard.2003.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2002] [Revised: 03/09/2003] [Accepted: 03/11/2003] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of the study was to compare the influence of dual-chamber pacing vs. nonsurgical septal reduction on hemodynamic and morphological parameters in patients with obstructive form of hypertrophic cardiomyopathy. METHODS Nineteen patients with dual-chamber pacing (group I) and 9 patients who underwent nonsurgical septal reduction (group II) were studied at baseline and after a 6-month follow-up. The changes of left ventricular outflow tract gradient and posterior wall thickness (as an index of left ventricular hypertrophy regression) were compared. RESULTS The baseline left ventricular outflow tract gradient was comparable between group I and group II (77+/-25 vs. 82+/-25 mm Hg, p>0.05). At 6-month follow-up, the left ventricular outflow tract gradient was reduced to a similar level in both groups (28+/-19 vs. 25+/-12 mm Hg, p>0.05). At baseline, posterior wall hypertrophy was comparable between groups (12.9+/-1.7 vs. 13.6+/-2.2 mm, p>0.05). During follow-up, the posterior wall thickness was unchanged in the pacing group (12.9+/-1.7 vs. 12.6+/-1.6 mm, p>0.05), whereas nonsurgical septal reduction induced regression of left ventricular hypertrophy in myocardial region remote from the infarcted septal segment (13.6+/-2.2 vs. 10.5+/-2.3 mm, p<0.003). CONCLUSION Despite comparable reduction of instantaneous left ventricular outflow tract gradient, the nonsurgical septal reduction decreased posterior wall thickness, whereas pacing did not reduce left ventricular hypertrophy. Thus, regression of left ventricular hypertrophy that appeared solely after nonsurgical septal reduction may reflect the more permanent reduction of left ventricular pressure overload. Thus, not only hemodynamic but also morphological benefit from nonsurgical septal reduction seems to indicate the superiority of this method over dual-chamber pacing.
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Affiliation(s)
- P Petkow Dimitrow
- Institute of Cardiology, Collegium Medicum Jagiellonian University, Kraków, Poland.
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98
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Hayes DL, Furman S. Cardiac Pacing:. How It Started, Where We Are, Where We Are Going. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:693-704. [PMID: 15125737 DOI: 10.1111/j.1540-8159.2004.00515.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- David L Hayes
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Mayo College of Medicine, Rochester, Minnesota 55905, USA.
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Affiliation(s)
- David L Hayes
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Mayo College of Medicine, Rochester, Minnesota 55905, USA.
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Affiliation(s)
- Rick A Nishimura
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
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