1
|
Sun D, Schaff HV, Greason KL, Huang Y, Bagameri G, Pochettino A, DeValeria PA, Dearani JA, Daly RC, Landolfo KP, Wiechmann RJ, Pislaru SV, Crestanello JA. Mechanical or biological prosthesis for aortic valve replacement in patients aged 45 to 74 years. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00551-8. [PMID: 38960283 DOI: 10.1016/j.jtcvs.2024.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 06/09/2024] [Accepted: 06/27/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE The selection of valve prostheses for patients undergoing surgical aortic valve replacement remains controversial. In this study, we compared the long-term outcomes of patients undergoing aortic valve replacement with biological or mechanical aortic valve prostheses. METHODS We evaluated late results among 5762 patients aged 45 to 74 years who underwent biological or mechanical aortic valve replacement with or without concomitant coronary artery bypass from 1989 to 2019 at 4 medical centers. The Cox proportional hazards model was used to compare late survival; the age-dependent effect of prosthesis type on long-term survival was evaluated by an interaction term between age and prosthesis type. Incidences of stroke, major bleeding, and reoperation on the aortic valve after the index procedure were compared between prosthesis groups. RESULTS Overall, 61% (n = 3508) of patients received a bioprosthesis. The 30-day mortality rate was 1.7% (n = 58) in the bioprosthesis group and 1.5% (n = 34) in the mechanical group (P = .75). During a mean follow-up of 9.0 years, the adjusted risk of mortality was higher in the bioprosthesis group (hazard ratio, 1.30, P < .001). The long-term survival benefit associated with mechanical prosthesis persisted until 70 years of age. Bioprosthesis (vs mechanical prosthesis) was associated with a similar risk of stroke (P = .20), lower risk of major bleeding (P < .001), and higher risk of reoperation (P < .001). CONCLUSIONS Compared with bioprostheses, mechanical aortic valves are associated with a lower adjusted risk of long-term mortality in patients aged 70 years or less. Patients aged less than 70 years undergoing surgical aortic valve replacement should be informed of the potential survival benefit of mechanical valve substitutes.
Collapse
Affiliation(s)
- Daokun Sun
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Ying Huang
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | | | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Kevin P Landolfo
- Division of Cardiovascular Surgery, Mayo Clinic, Jacksonville, Fla
| | | | - Sorin V Pislaru
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minn
| | | |
Collapse
|
2
|
Ommen SR, Ho CY, Asif IM, Balaji S, Burke MA, Day SM, Dearani JA, Epps KC, Evanovich L, Ferrari VA, Joglar JA, Khan SS, Kim JJ, Kittleson MM, Krittanawong C, Martinez MW, Mital S, Naidu SS, Saberi S, Semsarian C, Times S, Waldman CB. 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2324-2405. [PMID: 38727647 DOI: 10.1016/j.jacc.2024.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2024]
Abstract
AIM The "2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy" provides recommendations to guide clinicians in the management of patients with hypertrophic cardiomyopathy. METHODS A comprehensive literature search was conducted from September 14, 2022, to November 22, 2022, encompassing studies, reviews, and other evidence on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through May 23, 2023, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Hypertrophic cardiomyopathy remains a common genetic heart disease reported in populations globally. Recommendations from the "2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy" have been updated with new evidence to guide clinicians.
Collapse
|
3
|
Ommen SR, Ho CY, Asif IM, Balaji S, Burke MA, Day SM, Dearani JA, Epps KC, Evanovich L, Ferrari VA, Joglar JA, Khan SS, Kim JJ, Kittleson MM, Krittanawong C, Martinez MW, Mital S, Naidu SS, Saberi S, Semsarian C, Times S, Waldman CB. 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1239-e1311. [PMID: 38718139 DOI: 10.1161/cir.0000000000001250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
AIM The "2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy" provides recommendations to guide clinicians in the management of patients with hypertrophic cardiomyopathy. METHODS A comprehensive literature search was conducted from September 14, 2022, to November 22, 2022, encompassing studies, reviews, and other evidence on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through May 23, 2023, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Hypertrophic cardiomyopathy remains a common genetic heart disease reported in populations globally. Recommendations from the "2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy" have been updated with new evidence to guide clinicians.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Victor A Ferrari
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
- SCMR representative
| | | | - Sadiya S Khan
- ACC/AHA Joint Committee on Performance Measures representative
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Qamar Y, Schaff HV, Castro-Varela A, Cui H, Dearani JA, Geske JB, Eleid MF, Lee AT, Lahr B, Ommen SR. Outcomes of surgical septal myectomy for obstructive hypertrophic cardiomyopathy after previous septal reduction therapy. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00380-5. [PMID: 38750691 DOI: 10.1016/j.jtcvs.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVE To compare early and late outcomes of septal myectomy in patients with obstructive hypertrophic cardiomyopathy who presented with residual or recurrent left ventricular outflow tract (LVOT) obstruction after previous septal-reduction therapy (SRT). METHODS From January 1989 to March 2022, 145 patients underwent reintervention by septal myectomy for residual LVOT obstruction after previous SRT; 72 patients had previous alcohol septal ablation (ASA) and 73 had previous surgical septal myectomy. Baseline patient characteristics, echocardiographic parameters, and surgical outcomes were compared between these 2 groups. RESULTS Patients who had previous ASA were more likely to be male (50.0% vs 30.1%; P = .015), be older (median age 57.5 years vs 48.3 years; P < .001), and have a greater body mass index (32.7 kg/m2 vs 30.0 kg/m2; P = .011). After repeat SRT by septal myectomy, there was no significant difference in the incidence of postoperative complete heart block, necessitating permanent pacemaker, between the 2 groups (8.3% vs 2.7%; P = .151). One (0.7%) patient died within 30 days of surgery. Over a median follow-up of 7.5 years (interquartile range, 3.0-13.8), there were 20 deaths. Kaplan-Meier 5-, 10-, and 15-year survival rates were 100%, 91%, and 76% for the previous septal myectomy group, and 93%, 81%, and 64% for the previous ASA group (P = .207). CONCLUSIONS Septal myectomy for residual or recurrent LVOT obstruction in patients who had previous ASA is safe, with an acceptably low rate of postoperative complete heart block. Surgical outcomes and late survival rates in patients with complete heart block ASA were satisfactory and comparable with patients who underwent repeat myectomy.
Collapse
Affiliation(s)
- Younus Qamar
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | | | - Hao Cui
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Jeffrey B Geske
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Alexander T Lee
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minn
| | - Brian Lahr
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minn
| | - Steve R Ommen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| |
Collapse
|
5
|
Pelliccia F, Moscarella E, Calabrò P, Andò G. Alternative Approaches for Alcohol Septal Ablation in Hypertrophic Cardiomyopathy: The Call for a Personalized Treatment. Am J Cardiol 2024; 217:164-166. [PMID: 38490337 DOI: 10.1016/j.amjcard.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/11/2024] [Indexed: 03/17/2024]
Affiliation(s)
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Caserta, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Caserta, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| |
Collapse
|
6
|
Zhou M, Li Z, Liu Y, Fang Y, Qin L, Yang W, Yan F, Zhao Q. Transapical intramyocardial septal microwave ablation in treatment of hypertrophic obstructive cardiomyopathy: 12-month outcomes of a swine model. J Cardiothorac Surg 2024; 19:205. [PMID: 38615019 PMCID: PMC11015544 DOI: 10.1186/s13019-024-02677-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 03/23/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND To date, the extended Morrow procedure is considered the gold standard treatment for patients with obstructive hypertrophic cardiomyopathy who experience severe symptoms and are unresponsive to medication treatment. We therefore aimed to perform transapical intramyocardial septal microwave ablation to reduce the thickness of the interventricular septum myocardium in a minimally invasive method. METHODS Fourteen swine were divided to form either a microwave ablation group (n = 7) or a sham group (n = 7). In the microwave ablation group, a transapical microwave antenna was inserted into the septum to ablate each myocardial segment at 40 W for 1 min, while in the sham group, the same operation was performed but without power output. We used echocardiography, electrocardiogram, during the operation. And added computerized tomography, cardiac nuclear magnetic resonance during follow-up. RESULTS Segment hypokinesis was observed in all swine immediately following ablation. Compared with the sham group, the thickness of ablated segments in the ablation group decreased significantly 1 month post-operation (ablation group, 5.53 ± 1.00 mm vs. 8.03 ± 1.15 mm, respectively, P < 0.01; sham group, 8.40 ± 0.94 mm vs. 8.21 ± 1.09 mm, respectively, P = 0.081), and the outcome was still observed 1 year post-operation (ablation group, 3.36 ± 0.85 mm vs. 8.03 ± 1.15 mm, respectively, P < 0.01). No perforation of the septum was observed during the procedure or follow-up, and no heart failure or sudden cardiac death occurred during postoperative feeding. CONCLUSIONS Transapical intramyocardial septal microwave ablation can effectively and safely produce a large region of necrosis. This technique can potentially mimic surgical myectomy while avoiding cardiopulmonary bypass and median sternotomy in high-risk hypertrophic obstructive cardiomyopathy patients.
Collapse
Affiliation(s)
- Mi Zhou
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Zhaolong Li
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Yun Liu
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Yuehua Fang
- Department of Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Le Qin
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Wenjie Yang
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Fuhua Yan
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| |
Collapse
|
7
|
Amaral Marques C, Laura Costa A, Martins E. Left bundle branch block-induced dilated cardiomyopathy: Definitions, pathophysiology, and therapy. Rev Port Cardiol 2024:S0870-2551(24)00081-7. [PMID: 38615881 DOI: 10.1016/j.repc.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 11/18/2023] [Accepted: 02/07/2024] [Indexed: 04/16/2024] Open
Abstract
Left bundle branch block (LBBB) is a frequent finding in patients with heart failure (HF), particularly in those with dilated cardiomyopathy (DCM). LBBB has been commonly described as a consequence of DCM development. However, a total recovery of left ventricular (LV) function after cardiac resynchronization therapy (CRT), observed in patients with LBBB and DCM, has led to increasing acknowledgement of LBBB-induced dilated cardiomyopathy (LBBB-iDCM) as a specific pathological entity. Its recognition has important clinical implications, as LBBB-iDCM patients may benefit from an early CRT strategy rather than medical HF therapy only. At present, there are no definitive diagnostic criteria enabling the universal identification of LBBB-iDCM, and no defined therapeutic approach in this subgroup of patients. This review compiles the main findings about LBBB-iDCM pathophysiology and the current proposed diagnostic criteria and therapeutic approach.
Collapse
Affiliation(s)
- Catarina Amaral Marques
- Faculty of Medicine - University of Porto, Porto, Portugal; Department of Cardiology, Centro Hospitalar Universitário São João, Porto, Portugal.
| | | | - Elisabete Martins
- Faculty of Medicine - University of Porto, Porto, Portugal; Department of Cardiology, Centro Hospitalar Universitário São João, Porto, Portugal
| |
Collapse
|
8
|
Harano Y, Sahashi Y, Kawase Y, Matsuo H. Comparative Evaluation of Alcohol Septal Ablation: Left Anterior Descending Versus Non-left Anterior Descending Artery Approaches. Am J Cardiol 2024; 216:54-62. [PMID: 38402924 DOI: 10.1016/j.amjcard.2024.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/05/2024] [Accepted: 01/27/2024] [Indexed: 02/27/2024]
Abstract
Alcohol septal ablation (ASA) is performed for symptomatic drug-refractory hypertrophic obstructive cardiomyopathy to reduce the left ventricular outflow tract pressure gradient (LVOTPG) by injecting ethanol into a septal branch that perforates the septal bulge. The target septal branches usually arise directly from the left anterior descending (LAD) artery; however, vessels from a non-LAD artery can be selected in some cases. This study aimed to compare the effectiveness and safety between ASA performed using a septal branch arising from a non-LAD artery and a branch arising from the LAD artery. This single-center, retrospective, observational cohort study comprised patients with hypertrophic obstructive cardiomyopathy who underwent ASA at the Gifu Heart Centre between 2011 and 2022. The effectiveness and safety of ASA using the 2 artery types were compared. The primary end points were LVOTPG and procedure success, determined as LVOTPG <30 mm Hg after 1 year. Of 33 patients (mean age 66.4 ± 13.0 years, 13 men), 18 patients who underwent ASA using only LAD branches and 15 patients who underwent ASA using only non-LAD branches demonstrated no significant difference in the decrease in LVOTPG during the follow-up period (-99.1 ± 47.4 mm Hg/year vs -75.7 ± 39.2 mm Hg/year, respectively, p = 0.19). The procedure success at 1 year was not significantly different between the 2 groups (93.3% and 84.6%, respectively, p = 0.58). ASA performed using septal branches from non-LAD arteries could be an alternative treatment approach when appropriate septal branches are missing or desirable effects cannot be obtained from ASA using LAD branches.
Collapse
Affiliation(s)
- Yoshihiro Harano
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Yuki Sahashi
- Division of Cardiovascular Medicine, Gifu University Hospital, Gifu, Japan; Division of Artificial Intelligence in Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Yoshiaki Kawase
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan.
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| |
Collapse
|
9
|
Ngan HT, Tse HF. Expanding indications for pulsed-field ablation beyond the treatment of cardiac arrhythmias? Heart Rhythm 2024; 21:268-269. [PMID: 38065420 DOI: 10.1016/j.hrthm.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 01/15/2024]
Affiliation(s)
- Ho-Ting Ngan
- Division of Cardiology, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China; Cardiac and Vascular Center, Hong Kong University Shenzhen Hospital, Shenzhen, China; Hong Kong-Guangdong Joint Laboratory on Stem Cell and Regenerative Medicine, The University of Hong Kong, Hong Kong SAR, China; Center for Translational Stem Cell Biology, Hong Kong SAR, China.
| |
Collapse
|
10
|
Schaff HV, Juarez-Casso FM. Treatment Strategies for Hypertrophic Cardiomyopathy: Surgical. Am J Cardiol 2024; 212S:S53-S63. [PMID: 38368037 DOI: 10.1016/j.amjcard.2023.10.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 02/19/2024]
Abstract
Septal myectomy is a well-established procedure for septal reduction in patients with obstructive hypertrophic cardiomyopathy (HCM) who have not responded to medical treatment. The surgical approach is tailored to the unique pathophysiology and septal morphology of the patient. Extended transaortic myectomy is the standard procedure for patients with isolated subaortic obstruction, the most common type of HCM. However, transapical myectomy is a useful adjunct for patients with long or midventricular obstruction and is our preferred technique for ventricular enlargement in patients with severe symptomatic diastolic heart failure because of extensive apical hypertrophy. Septal myectomy provides excellent postoperative outcomes as regards symptom relief and functional improvement, and operative morbidity and mortality rates are low in experienced centers. This article summarizes our current surgical management of patients with HCM and details operative methods and outcomes.
Collapse
Affiliation(s)
- Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | | |
Collapse
|
11
|
Li J, Wei X. Transapical beating-heart septal myectomy for hypertrophic cardiomyopathy with latent obstruction. Eur J Cardiothorac Surg 2024; 65:ezad425. [PMID: 38113423 PMCID: PMC10903174 DOI: 10.1093/ejcts/ezad425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/20/2023] [Accepted: 12/18/2023] [Indexed: 12/21/2023] Open
Abstract
OBJECTIVES A novel transapical beating-heart septal myectomy (TA-BSM) procedure was performed for patients with latent obstruction through the left intercostal incision and without cardiopulmonary bypass. This study aims to demonstrate the experience of the TA-BSM procedure for patients with latent obstruction and compare outcomes to patients with resting obstruction. METHODS We studied 120 symptomatic hypertrophic obstructive cardiomyopathy patients (33 with latent obstruction and 87 with resting obstruction) who underwent TA-BSM. Demographic profiles, echocardiogram-derived ventricular morphology and haemodynamics and clinical outcomes were analysed. RESULTS There were no important differences in baseline clinical characteristics between patients with latent obstruction and resting obstruction, including age, symptoms, comorbidities and medical history. Patients with latent obstruction had lower basal septum thickness, higher midventricular wall thickness, smaller left atrial chamber size and more frequency of mitral subvalvular anomalies. There was no difference in early (<30 days) deaths (0/33 vs 1/87, P > 0.999) and mid-term survival between patients with latent obstruction and resting obstruction. At 6 months after surgery, 31 (93.9%) patients with latent obstruction and 80 (92.0%) with resting obstruction achieved optimal procedural success, which was defined as a maximal gradient (after provocation) <30 mmHg and mitral regurgitation ≤ grade 1+ without mortality. Maximal left ventricular outflow tract gradient, basal septum thickness, midventricular wall thickness, mitral regurgitation grade and left atrial chamber size were significantly decreased after TA-BSM. In the follow-up, the New York Heart Association class was significantly improved following surgery. CONCLUSIONS TA-BSM preserved favourable gold-standard guideline desired outcomes through real-time echocardiographic-guided resection. Equipoise of outcomes for this procedure regardless of degree of resting left ventricular outflow tract gradients supports operative management with this approach in symptomatic patients with latent obstruction.
Collapse
Affiliation(s)
- Jiangtao Li
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China
- NHC Key Laboratory of Organ Transplantation, Ministry of Health, Wuhan, China
| | - Xiang Wei
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China
- NHC Key Laboratory of Organ Transplantation, Ministry of Health, Wuhan, China
| |
Collapse
|
12
|
Koo HJ, Lee SA, Jung SH, Kang JW, Yang DH. Tailored Planning of Surgical Myectomy in Obstructive Hypertrophic Cardiomyopathy. Radiographics 2024; 44:e230050. [PMID: 38060425 DOI: 10.1148/rg.230050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Hypertrophic cardiomyopathy (HCM) is a genetic myocardial disease characterized by abnormal thickening of the myocardium caused by myocardial disarray and interstitial fibrosis. HCM is associated with sudden cardiac-related events, such as ventricular fibrillation, tachycardia, and syncope. Moreover, left ventricular or midcavity obstruction due to the thickened myocardium can result in severe heart failure and mortality in patients with HCM. Surgical myectomy is a standard treatment option for patients with symptomatic obstructive HCM; however, it is a complex procedure that requires careful planning and execution to avoid complications, such as residual flow obstruction, persistent obliteration of the left ventricular cavity in systole, or iatrogenic ventricular septal defects. Therefore, a thorough understanding of the mechanics of HCM and precise evaluation of the location and extent of the hypertrophic myocardium to be removed are crucial for preoperative planning. Multiphase cardiac CT postprocessing is important for preoperative evaluation and planning of surgical myectomy in patients with HCM. In this review, the authors highlight use of multiphase cardiac CT with step-by-step postprocessing methods to simulate successful surgical myectomy. The transaortic surgeon's view on end-diastolic phase images accurately represents the surgical field. Moreover, myocardial segmentation can be used to generate volume-rendered images and three-dimensional printing. CT evaluation can also assist in identifying concurrent abnormalities, such as mitral valve or papillary muscle abnormalities. In addition to CT, other imaging modalities for preoperative evaluation of HCM and postmyectomy evaluation methods are presented. ©RSNA, 2023 Test Your Knowledge questions in the supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.
Collapse
Affiliation(s)
- Hyun Jung Koo
- From the Department of Radiology and Research Institute of Radiology, Cardiac Imaging Center (H.J.K., J.W.K., D.H.Y.), Division of Cardiology, Internal Medicine, Cardiac Imaging Center (S.A.L.), and Department of Thoracic and Cardiovascular Surgery (S.H.J.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea
| | - Seung-Ah Lee
- From the Department of Radiology and Research Institute of Radiology, Cardiac Imaging Center (H.J.K., J.W.K., D.H.Y.), Division of Cardiology, Internal Medicine, Cardiac Imaging Center (S.A.L.), and Department of Thoracic and Cardiovascular Surgery (S.H.J.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea
| | - Sung Ho Jung
- From the Department of Radiology and Research Institute of Radiology, Cardiac Imaging Center (H.J.K., J.W.K., D.H.Y.), Division of Cardiology, Internal Medicine, Cardiac Imaging Center (S.A.L.), and Department of Thoracic and Cardiovascular Surgery (S.H.J.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea
| | - Joon-Won Kang
- From the Department of Radiology and Research Institute of Radiology, Cardiac Imaging Center (H.J.K., J.W.K., D.H.Y.), Division of Cardiology, Internal Medicine, Cardiac Imaging Center (S.A.L.), and Department of Thoracic and Cardiovascular Surgery (S.H.J.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea
| | - Dong Hyun Yang
- From the Department of Radiology and Research Institute of Radiology, Cardiac Imaging Center (H.J.K., J.W.K., D.H.Y.), Division of Cardiology, Internal Medicine, Cardiac Imaging Center (S.A.L.), and Department of Thoracic and Cardiovascular Surgery (S.H.J.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea
| |
Collapse
|
13
|
Aimo A, Milandri A, Barison A, Pezzato A, Morfino P, Vergaro G, Merlo M, Argirò A, Olivotto I, Emdin M, Finocchiaro G, Sinagra G, Elliott P, Rapezzi C. Electrocardiographic abnormalities in patients with cardiomyopathies. Heart Fail Rev 2024; 29:151-164. [PMID: 37848591 PMCID: PMC10904564 DOI: 10.1007/s10741-023-10358-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 10/19/2023]
Abstract
Abnormalities in impulse generation and transmission are among the first signs of cardiac remodeling in cardiomyopathies. Accordingly, 12-lead electrocardiogram (ECG) of patients with cardiomyopathies may show multiple abnormalities. Some findings are suggestive of specific disorders, such as the discrepancy between QRS voltages and left ventricular (LV) mass for cardiac amyloidosis or the inverted T waves in the right precordial leads for arrhythmogenic cardiomyopathy. Other findings are less sensitive and/or specific, but may orient toward a specific diagnosis in a patient with a specific phenotype, such as an increased LV wall thickness or a dilated LV. A "cardiomyopathy-oriented" mindset to ECG reading is important to detect the possible signs of an underlying cardiomyopathy and to interpret correctly the meaning of these alterations, which differs in patients with cardiomyopathies or other conditions.
Collapse
Affiliation(s)
- Alberto Aimo
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
| | | | - Andrea Barison
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Andrea Pezzato
- Center for Diagnosis and Management of Cardiomyopathies, Cardiothoracovascular Department Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Paolo Morfino
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Giuseppe Vergaro
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Marco Merlo
- Center for Diagnosis and Management of Cardiomyopathies, Cardiothoracovascular Department Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | | | - Iacopo Olivotto
- Department of Experimental and Clinical Medicine, University of Florence, Meyer Children Hospital Florence, Florence, Italy
| | - Michele Emdin
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Gherardo Finocchiaro
- Royal Brompton and Harefield Hospital, London, UK
- St George's University of London, London, UK
| | - Gianfranco Sinagra
- Center for Diagnosis and Management of Cardiomyopathies, Cardiothoracovascular Department Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Perry Elliott
- UCL Centre for Heart Muscle Disease and Lead of the Inherited Cardiovascular Disease Unit, Bart's Heart Centre, London, UK
- Cardiology Centre, University of Ferrara, Ferrara, Italy
| | - Claudio Rapezzi
- UCL Centre for Heart Muscle Disease and Lead of the Inherited Cardiovascular Disease Unit, Bart's Heart Centre, London, UK
| |
Collapse
|
14
|
Moreno M, Ji W, Yee B, Lei K, Ahsan C. Complete Heart Block After Aortic Valve Repair and Septal Myectomy in a Patient With Rheumatic Heart Disease. Cureus 2024; 16:e53347. [PMID: 38435860 PMCID: PMC10907803 DOI: 10.7759/cureus.53347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Surgical myectomy with concomitant valvular repair has been demonstrated to be safe in the treatment of hypertrophic obstructive cardiomyopathy (HOCM). It is unclear which risk factors predispose patients to develop complete heart block (CHB). We present a unique case of a 66-year-old female with rheumatic heart disease and HOCM admitted for aortic valve (AV) repair and septal myectomy, complicated by a presentation of complete heart block. The histology slide showed fibrosis of the septum, suggesting atrioventricular conduction disease from rheumatic fever, which likely contributed to her presentation. This case highlights the importance of elucidating the etiology of HOCM before undergoing cardiac surgery to guide postsurgical management and improve clinical outcomes.
Collapse
Affiliation(s)
- Marvi Moreno
- Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas (UNLV), Las Vegas, USA
| | - Wilbur Ji
- Internal Medicine, University of California, San Francisco, San Francisco, USA
| | - Brianna Yee
- Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas (UNLV), Las Vegas, USA
| | - Kachon Lei
- Cardiology, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas (UNLV), Las Vegas, USA
| | - Chowdhury Ahsan
- Internal Medicine and Cardiology, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas (UNLV), Las Vegas, USA
| |
Collapse
|
15
|
Rowin EJ, Link MS, Maron MS, Maron BJ. Evolving Contemporary Management of Atrial Fibrillation in Hypertrophic Cardiomyopathy. Circulation 2023; 148:1797-1811. [PMID: 38011245 DOI: 10.1161/circulationaha.123.065037] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM) with clinical and subclinical episodes occurring in nearly one-half of patients. AF in HCM historically has been characterized as a decisive disease complication associated with substantial risk for thromboembolic stroke and increased morbidity and mortality. However, there have been many advances in treatment strategy resulting in improved outcomes for this patient group. For example, stroke risk in HCM has been greatly reduced by using systemic oral anticoagulation initiated after the first clinical (symptomatic) AF episode, usually with preference given to direct anticoagulants over warfarin. In contrast, stroke risk scoring systems (such as CHA2DS2-VASc score) are not informative in HCM given the substantial potential for stroke events in patients with low scores, and therefore should not be used for anticoagulation decisions in this disease. A novel risk score specifically designed for HCM (HCM-AF score) can reliably identify most patients with HCM at risk for future AF. Although a strategy focused on controlling ventricular rate is effective in asymptomatic (or minimally symptomatic) patients with AF, restoring and maintaining sinus rhythm is required for most patients with marked AF symptom burden and impaired quality of life. Several antiarrhythmic drugs such as sotalol, disopyramide, and amiodarone, can be effective in suppressing AF episodes; albeit safe, long-term efficacy is supported by only limited data. Catheter AF ablation has emerged as an important treatment option for some patients, although freedom from AF after a single ablation is relatively low (35% at 3 years), multiple ablations and the concomitant use of antiarrhythmic drugs can control AF with more than two-thirds of patients maintaining sinus rhythm at 5 years. Surgical AF ablation with biatrial Cox-Maze IV performed as an adjunctive procedure during myectomy can reduce symptomatic AF episodes (70% of patients free from AF at 5 years). For the vast majority of patients who have HCM with AF, the implementation of contemporary therapies has allowed for improved quality of life and low HCM-related mortality.
Collapse
Affiliation(s)
- Ethan J Rowin
- Lahey Hospital and Medical Center, Burlington, MA (E.J.R., M.S.M., B.J.M.)
| | - Mark S Link
- University of Texas Southwestern Medical Center, Dallas (M.S.L.)
| | - Martin S Maron
- Lahey Hospital and Medical Center, Burlington, MA (E.J.R., M.S.M., B.J.M.)
| | - Barry J Maron
- Lahey Hospital and Medical Center, Burlington, MA (E.J.R., M.S.M., B.J.M.)
| |
Collapse
|
16
|
Faisaluddin M, Ahmed A, Patel H, Thakkar S, Patel B, Balasubramanian S, Feitell SC, Shekar P, Rowin E, Maron M, Ganatra S, Dani SS. Surgical Outcomes of Septal Myectomy With and Without Mitral Valve Surgeries in Hypertrophic Cardiomyopathy: a National Propensity-Matched Analysis (2005 to 2020). Am J Cardiol 2023; 205:276-282. [PMID: 37619494 DOI: 10.1016/j.amjcard.2023.07.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/20/2023] [Accepted: 07/30/2023] [Indexed: 08/26/2023]
Abstract
The management of concomitant mitral valve (MV) disease in patients with hypertrophic cardiomyopathy (HCM) remains controversial. The 2020 American Heart Association/American College of Cardiology HCM guidelines recommend that MV replacement (MVR) at the time of myectomy should not be performed for the sole purpose of relieving outflow obstruction. At the national level, limited data exist on the surgical outcomes of MV repair/replacement in patients with HCM who underwent septal myectomy (SM). Hospitalizations of patients with HCM who underwent SM between 2005 and 2020 were identified using International Classification of Diseases, Ninth and Tenth Revision codes (International Classification of Diseases, Ninth and Tenth Revision Clinical Modification/Procedure Coding System). The 3 comparison cohorts were SM alone, MV repair, and MVR with concomitant SM. After propensity matching, 2 cohorts, SM + MVR versus SM + MV repair, were studied for surgical outcomes. Demographic characteristics, baseline co-morbidities, procedural complications, inpatient mortality, length of stay, and cost of hospitalization were compared between the propensity-matched cohorts. A total of 16,797 SM procedures were identified from 2005 to 2020. Among them, 11,470 hospitalizations had SM alone (68.2%), SM + MVR was seen in 3,101 (18.4%), and SM + MV repair comprised 2,226 (13.2%). After propensity matching, the MVR and MV repair formed the matched cohorts of 1,857. There were no significant differences in the odds of cardiogenic shock (adjusted odds ratio [aOR] 0.88, 95% confidence interval [CI] 0.63 to 1.24, p = 0.49), mechanical circulatory support requirement (aOR 0.58, 95% CI 0.37 to 0.90, p = 0.015), stroke (aOR 1.27, 95% CI 0.81 to 1.99, p = 0.29), and major bleeding (aOR 0.52, 95% CI 0.34 to 0.79, p = 0.0026) between the comparison groups. MVR, compared with MV repair, was associated with a higher risk of procedural mortality (8.02% vs 3.18%, aOR 2.98, 95% CI 2.05 to 4.33, p <0.0001), complete heart block (16.36% vs 12.15%, aOR 1.76, 95% CI 1.44 to 2.12, p <0.0001), and the need for permanent pacemaker (16.39% vs 10.62%, aOR 1.83, 95% CI 1.41 to 2.38, p <0.0001). The total length of hospital stay and median hospitalization cost was higher in the MVR group. SM in HCM concomitant with MVR is associated with higher procedural mortality and in-hospital complication risk. These real-world data support the 2020 American Heart Association/American College of Cardiology guidelines that in patients who are candidates for surgical myectomy, MVR should not be performed as part of the operative strategy for relieving outflow obstruction in HCM.
Collapse
Affiliation(s)
- Mohammed Faisaluddin
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Asmaa Ahmed
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Harsh Patel
- Department of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois
| | | | - Bhavin Patel
- Department of Internal Medicine, Saint Joseph Mercy-Oakland, Pontiac, Michigan
| | - Senthil Balasubramanian
- Division of Cardiovascular Medicine, NorthShore University Health System-Metro Chicago, Evanston, Illinois
| | - Scott C Feitell
- Division of Cardiovascular Medicine, Rochester General Hospital, Rochester, New York
| | - Prem Shekar
- Division of Cardiothoracic Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Ethan Rowin
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Martin Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Sarju Ganatra
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Sourbha S Dani
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts.
| |
Collapse
|
17
|
Ha KE, Choi K, Lee H, Gwak S, Kim K, Cho I, Hong G, Ha J, Shim CY. Effects of septal myectomy on left atrial and left ventricular function in obstructive hypertrophic cardiomyopathy. ESC Heart Fail 2023; 10:2939-2947. [PMID: 37483012 PMCID: PMC10567661 DOI: 10.1002/ehf2.14481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/04/2023] [Indexed: 07/25/2023] Open
Abstract
AIMS Mechanical function of the left atrium (LA) and the left ventricle (LV) has been demonstrated to be a prognostic factor in patients with hypertrophic cardiomyopathy (HCM). We explore whether myocardial mechanical function can be improved by septal reduction therapy in symptomatic obstructive HCM. METHODS AND RESULTS Among 65 patients who underwent septal myectomy for symptomatic obstructive HCM from 2006 to 2022, 44 were analysed after excluding those who underwent simultaneous valve repair or replacement or maze operation. LA and LV functional variables including LA strain and LV global longitudinal strain were evaluated by two-dimensional and speckle-tracking echocardiography and compared before and 1 year after surgery. After septal myectomy, LA volume index (58.1 ± 18.3 vs. 45.3 ± 14.6 mL/m2 , P = 0.001) decreased significantly. As LV end-systolic dimension increased after surgery, the LV ejection fraction decreased (73.8 ± 6.7 vs. 62.9 ± 8.3%, P < 0.001). LA strain (24.4 ± 9.3 vs. 30.5 ± 13.6%, P = 0.004) improved after septal myectomy, but LV global longitudinal strain deteriorated (-12.6 ± 3.6 vs. -11.6 ± 4.3%, P = 0.033), mainly related to worsening non-septal longitudinal strain (-14.4 ± 4.3 vs. -10.9 ± 8.4%, P = 0.005). CONCLUSIONS As haemodynamic loads due to LV outflow tract obstruction was relieved through surgical septal reduction therapy in patients with symptomatic obstructive HCM, there was a significant reduction in LA volume and restoration of LA mechanical dysfunction. However, LV mechanical dysfunction deteriorated even after surgical septal reduction therapy.
Collapse
Affiliation(s)
- Kyung Eun Ha
- Division of CardiologySeverance Cardiovascular Hospital, Yonsei University College of MedicineSeoulKorea
| | - Kang‐Un Choi
- Department of Internal Medicine, Division of CardiologyYeoungnam University College of MedicineDaeguKorea
| | - Hee‐Jung Lee
- Division of CardiologySeverance Cardiovascular Hospital, Yonsei University College of MedicineSeoulKorea
| | - Seo‐Yeon Gwak
- Division of CardiologySeverance Cardiovascular Hospital, Yonsei University College of MedicineSeoulKorea
| | - Kyu Kim
- Division of CardiologySeverance Cardiovascular Hospital, Yonsei University College of MedicineSeoulKorea
| | - Iksung Cho
- Division of CardiologySeverance Cardiovascular Hospital, Yonsei University College of MedicineSeoulKorea
| | - Geu‐Ru Hong
- Division of CardiologySeverance Cardiovascular Hospital, Yonsei University College of MedicineSeoulKorea
| | - Jong‐Won Ha
- Division of CardiologySeverance Cardiovascular Hospital, Yonsei University College of MedicineSeoulKorea
| | - Chi Young Shim
- Division of CardiologySeverance Cardiovascular Hospital, Yonsei University College of MedicineSeoulKorea
| |
Collapse
|
18
|
Mehra N, Veselka J, Smedira N, Desai MY. Invasive therapies for symptomatic obstructive hypertrophic cardiomyopathy. Prog Cardiovasc Dis 2023; 80:46-52. [PMID: 37652213 DOI: 10.1016/j.pcad.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/12/2023] [Indexed: 09/02/2023]
Abstract
Hypertrophic cardiomyopathy (HCM) is a genetic condition with multiple different genetic and clinical phenotypes. As awareness for HCM increases, it is important to also be familiar with potential treatment options for the disease. Treatment of HCM can be divided into two different categories, medical and interventional. Typically for obstructive forms of the disease, in which increased septal hypertrophy, abnormally placed papillary muscles, abnormalities in mitral valve or subvalvular apparatus, lead to dynamic left ventricular outflow tract (LVOT) obstruction, treatment is targeted at decreasing obstructive gradients and therefore symptoms. Medications like beta blockers, calcium channel blockers, disopyramide can often accomplish this. However, in patients with severe obstruction or symptoms refractory to medical therapy, either surgical correction of the LVOT obstruction or percutaneous via alcohol septal ablation, are treatment options. In this review, we will focus on the invasive treatment of hypertrophic obstructive cardiomyopathy.
Collapse
Affiliation(s)
- Nandini Mehra
- Department of Cardiovascular Medicine, Heart, Vascular Thoracic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195.
| | - Josef Veselka
- Department of Cardiology, University Hospital Motol and 2nd Medical School of Charles University, Prague, Czech Republic.
| | - Nicholas Smedira
- Department of Cardiothoracic Surgery, Heart, Vascular Thoracic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195.
| | - Milind Y Desai
- Department of Cardiovascular Medicine, Heart, Vascular Thoracic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195.
| |
Collapse
|
19
|
Fang J, Liu Y, Zhu Y, Li R, Wang R, Wang DW, Song Y, Li C, Chen Y, Cheng L, Zheng K, Zhao Y, Li S, Cheng C, Xia L, Chen X, Wan S, Wei X. First-in-Human Transapical Beating-Heart Septal Myectomy in Patients With Hypertrophic Obstructive Cardiomyopathy. J Am Coll Cardiol 2023; 82:575-586. [PMID: 37558369 DOI: 10.1016/j.jacc.2023.05.052] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/08/2023] [Accepted: 05/15/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND To simplify surgical septal reduction therapy for hypertrophic obstructive cardiomyopathy (HOCM), we developed a novel transapical beating-heart septal myectomy (TA-BSM) procedure. OBJECTIVES In this study, we sought to evaluate the clinical utility of TA-BSM in a first-in-human trial. METHODS Patients with HOCM were enrolled if they presented with drug-refractory disabling symptoms. TA-BSM was performed via minithoracotomy with the use of our beating-heart myectomy device under echocardiographic guidance, without the use of cardiopulmonary bypass. Repeated resections were performed to tailor the extent of the septal myectomy for sufficient abolishment of left ventricular outflow tract (LVOT) obstruction and mitral regurgitation (MR). The primary outcome measure was procedural success, defined by resting/provoked LVOT gradient <30/50 mm Hg and residual MR grade ≤1+ (of 4+) at 3-month follow-up. RESULTS A total of 47 patients aged 12 to 77 years were enrolled. Of the 46 patients who were followed for 3 months, 42 achieved procedural success. The maximal LVOT gradient decreased from 86 mm Hg (IQR: 67-114 mm Hg) at baseline to 19 mm Hg (IQR: 14-28 mm Hg) at 3 months. MR grade was ≤1+ in 3 patients at baseline and in 45 patients at 3 months. One patient died on postoperative day 10 owing to device-unrelated reasons. Other major adverse events included 1 delayed ventricular septal perforation and 1 intraoperative left ventricular apical tear. CONCLUSIONS TA-BSM is a safe and efficient minimally invasive procedure for septal reduction of heterogeneous HOCM. Compared with conventional septal myectomy, TA-BSM provides real-time evaluation to guide resection while reducing surgical trauma. (Transapical Beating-Heart Septal Myectomy in Patients With Hypertrophic Obstructive Cardiomyopathy; NCT05332691).
Collapse
Affiliation(s)
- Jing Fang
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China; NHC Key Laboratory of Organ Transplantation, Ministry of Health, Wuhan, China
| | - Yani Liu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Zhu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Li
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China; NHC Key Laboratory of Organ Transplantation, Ministry of Health, Wuhan, China
| | - Rui Wang
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China; NHC Key Laboratory of Organ Transplantation, Ministry of Health, Wuhan, China
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yunhu Song
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Chenhe Li
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China; NHC Key Laboratory of Organ Transplantation, Ministry of Health, Wuhan, China
| | - Yue Chen
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China; NHC Key Laboratory of Organ Transplantation, Ministry of Health, Wuhan, China
| | - Lin Cheng
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China; NHC Key Laboratory of Organ Transplantation, Ministry of Health, Wuhan, China
| | - Kangchao Zheng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun Zhao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiliang Li
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China; NHC Key Laboratory of Organ Transplantation, Ministry of Health, Wuhan, China
| | - Cai Cheng
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China; NHC Key Laboratory of Organ Transplantation, Ministry of Health, Wuhan, China
| | - Liming Xia
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoping Chen
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Song Wan
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
| | - Xiang Wei
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China; NHC Key Laboratory of Organ Transplantation, Ministry of Health, Wuhan, China.
| |
Collapse
|
20
|
Pujol-López M, Tolosana JM, Upadhyay GA, Mont L, Tung R. Left Bundle Branch Block: Characterization, Definitions, and Recent Insights into Conduction System Physiology. Cardiol Clin 2023; 41:379-391. [PMID: 37321688 DOI: 10.1016/j.ccl.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Left bundle branch block (LBBB) is not just a simple electrocardiogram alteration. The intricacies of this general terminology go beyond simple conduction block. This review puts together current knowledge on the historical concept of LBBB, clinical significance, and recent insights into the pathophysiology of human LBBB. LBBB is an entity that affects patient diagnosis (primary conduction disease, secondary to underlying pathology or iatrogenic), treatment (cardiac resynchronization therapy or conduction system pacing for heart failure), and prognosis. Recruiting the left bundle branch with conduction system pacing depends on the complex interaction between anatomy, site of pathophysiology, and delivery tools.
Collapse
Affiliation(s)
- Margarida Pujol-López
- Arrhythmia Section, Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Universitat de Barcelona, C/ Villarroel 170, Barcelona, Catalonia 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - José M Tolosana
- Arrhythmia Section, Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Universitat de Barcelona, C/ Villarroel 170, Barcelona, Catalonia 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Pritzker School of Medicine, University of Chicago, The University of Chicago Medicine, Heart and Vascular Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Lluís Mont
- Arrhythmia Section, Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Universitat de Barcelona, C/ Villarroel 170, Barcelona, Catalonia 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine, University of Chicago, The University of Chicago Medicine, Heart and Vascular Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
| |
Collapse
|
21
|
Yokoyama Y, Shimoda T, Shimada YJ, Shimamura J, Akita K, Yasuda R, Takayama H, Kuno T. Alcohol septal ablation versus surgical septal myectomy of obstructive hypertrophic cardiomyopathy: systematic review and meta-analysis. Eur J Cardiothorac Surg 2023; 63:7035942. [PMID: 36782361 DOI: 10.1093/ejcts/ezad043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/26/2023] [Indexed: 02/15/2023] Open
Abstract
OBJECTIVES To elucidate the optimal septal reduction therapy for obstructive hypertrophic cardiomyopathy, we conducted a meta-analysis comparing alcohol septal ablation (ASA) and septal myectomy. METHODS MEDLINE, EMBASE and Cochrane CENTRAL were searched to identify studies investigating the outcomes of ASA and septal myectomy in patients with obstructive hypertrophic cardiomyopathy in January 2023. The primary outcome of interest was all-cause mortality in studies with ≥1 year of follow-up. The secondary outcomes of interest comprised left ventricular outflow tract (LVOT) pressure gradient reduction and reoperations of LVOT. A subgroup analysis of all-cause mortality including studies with follow-up ≥5 years was performed. RESULTS 27 observational studies were included (15 968 patients). Analysis demonstrated similar all-cause mortality [hazard ratio (HR) (95% confidence interval) (CI) 1.24 (0.88-1.76); P = 0.21; I2 = 56%]. In contrast, ASA was associated with less reduction of LVOT pressure gradient and a reoperation rate [weighted mean difference (95% CI) 11.04 mmHg (5.60-16.48); P < 0.01; I2 = 64%, HR (95% CI) 9.14 (6.55-12.75); P < 0.001; I2 = 0%, respectively]. The subgroup analysis with follow-up ≥5 years revealed higher long-term mortality with ASA [HR (95% CI) 1.50 (1.04-2.15); P = 0.03; I2 = 52%]. CONCLUSIONS Although both septal reduction therapies were associated with similar all-cause mortality, ASA was associated with a higher rate of reoperation and less reduction of LVOT pressure gradient. Furthermore, all-cause mortality with follow-up ≥5 years showed favourable outcomes with septal myectomy, although the result is only hypothesis-generating given a subgroup analysis.
Collapse
Affiliation(s)
- Yujiro Yokoyama
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | | | - Yuichi J Shimada
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Junichi Shimamura
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University, Atlanta, GA, USA
| | - Keitaro Akita
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Risako Yasuda
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Hiroo Takayama
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|
22
|
Radu AD, Cojocaru C, Onciul S, Scarlatescu A, Zlibut A, Nastasa A, Dorobantu M. Cardiac Resynchronization Therapy and Hypertrophic Cardiomyopathy: A Comprehensive Review. Biomedicines 2023; 11:350. [PMID: 36830887 PMCID: PMC9952999 DOI: 10.3390/biomedicines11020350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 01/21/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is an inherited primary myocardial disease characterized by asymmetrical/symmetrical left ventricle (LV) hypertrophy, with or without LV outflow tract (LVOT) dynamic obstruction, and poor prognosis. Cardiac resynchronization therapy (CRT) has emerged as a minimally invasive tool for patients with heart failure (HF) with decreased LV ejection fraction (LVEF) and prolonged QRS duration of over 120 ms with or without left bundle branch block (LBBB). Several HCM patients are at risk of developing LBBB because of disease progression or secondary to septal myomectomy, while others might develop HF with decreased LVEF, alleged end-stage/dilated HCM, especially those with thin myofilament mutations. Several studies have shown that patients with myectomy-induced LBBB might benefit from left bundle branch pacing or CRT to relieve symptoms, improve exercise capacity, and increase LVEF. Otherwise, patients with end-stage/dilated HCM and prolonged QRS interval could gain from CRT in terms of NYHA class improvement, LV systolic performance increase and, to some degree, LV reverse remodeling. Moreover, several electrical and imaging parameters might aid proper selection and stratification of HCM patients to benefit from CRT. Nonetheless, current available data are scarce and further studies are still required to accurately clarify the view. This review reassesses the importance of CRT in patients with HCM based on current research by contrasting and contextualizing data from various published studies.
Collapse
Affiliation(s)
- Andrei Dan Radu
- Cardiology Department, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Cosmin Cojocaru
- Cardiology Department, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Sebastian Onciul
- Cardiology Department, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Alina Scarlatescu
- Cardiology Department, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
| | - Alexandru Zlibut
- Cardiology Department, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Alexandrina Nastasa
- Cardiology Department, “Elias” University Emergency Hospital, 011461 Bucharest, Romania
| | - Maria Dorobantu
- Cardiology Department, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| |
Collapse
|
23
|
Septal Myectomy: How I Teach It. Ann Thorac Surg 2023; 115:20-24. [PMID: 36089072 DOI: 10.1016/j.athoracsur.2022.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/22/2022] [Accepted: 08/27/2022] [Indexed: 12/31/2022]
|
24
|
Holst KA, Schaff HV, Smedira NG, Habermann EB, Day CN, Badhwar V, Takayama H, McCarthy PM, Dearani JA. Impact of Hospital Volume on Outcomes of Septal Myectomy for Hypertrophic Cardiomyopathy. Ann Thorac Surg 2022; 114:2131-2138. [PMID: 35779600 DOI: 10.1016/j.athoracsur.2022.05.062] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 05/14/2022] [Accepted: 05/25/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Left ventricular outflow tract obstruction is common among symptomatic patients with hypertrophic cardiomyopathy, yet septal reduction by surgical myectomy (septal myectomy [SM]) is performed infrequently in many centers. This study examined the possible relationship between institutional case volume and early outcomes of SM. METHODS The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for patients with hypertrophic cardiomyopathy who underwent SM from January 2012 to December 2019. The study defined center case volume categories as <1, 1 to 4.99, 5 to 9.99, and ≥10 cases performed on average per year. RESULTS The study population included 5935 patients at 481 centers with 933 surgeons. The range of average center volume was <1 to 138 cases per year. Overall early mortality was 2.6%, ventricular septal defect (VSD) occurred in 1.9%, and complete heart block occurred in 9.0%. Concomitant mitral valve (MV) repair was performed in 28.7%, and MV replacement was performed in 17.1%. In multivariable analysis, the lowest annual case volume (average <1 case/y) was consistently associated with greater early mortality (odds ratio [OR], 5.4; CI, 3.0-9.9; P < .001), greater risk of VSD (OR, 9.3; CI ,4.2-20.4; P < .001), increased incidence of complete heart block (OR, 2.0; CI, 1.5-2.7; P < .001), and a higher likelihood of MV replacement (OR, 9.4; CI, 7.5-11.8; P < .001). CONCLUSIONS Volume of SM cases varies widely among institutions reporting to the Society of Thoracic Surgeons Adult Cardiac Surgery Database. There appears to be an important association between surgical experience, as reflected by institutional case volume, and early outcomes, including mortality, as well as the occurrence of VSD, heart block, and MV replacement.
Collapse
Affiliation(s)
- Kimberly A Holst
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Nicholas G Smedira
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Elizabeth B Habermann
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Courtney N Day
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Columbia University, New York, New York
| | | | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
25
|
Zhang HD, Tang M, Zhang JT. Characteristics of Primary Bradyarrhythmia in Hypertrophic Cardiomyopathy: A 10-Year, Single-Center Analysis. J Cardiovasc Dev Dis 2022; 9:jcdd9110370. [PMID: 36354769 PMCID: PMC9698031 DOI: 10.3390/jcdd9110370] [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: 09/12/2022] [Revised: 10/20/2022] [Accepted: 10/27/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Secondary bradyarrhythmias in hypertrophic cardiomyopathy (HCM) have been extensively reported. The prevalence and characteristics of primary bradyarrhythmias in HCM have yet to be investigated. Methods: We retrospectively enrolled 101 consecutive patients with HCM who were referred to the arrhythmia center from May 2010 to October 2020. The clinical features of patients with bradyarrhythmias were analyzed. Results: Twenty-nine (28.7%) patients had primary bradyarrhythmias, and six (5.9%) patients had secondary third-degree atrioventricular block (AVB). Of the 29 patients, 17 (58.6%) had sinus node dysfunction (SND), 14 (48.3%) had AVB, and two (6.9%) had both SND and AVB. The median age was 62 years old, and 69% were male. Six (20.7%) patients had left ventricular obstructive outflow tract obstruction, 15 (51.7%) had a history of syncope, and one (3.4%) had a family history of HCM. Most patients (86.2%) had New York Heart Association functional class I or II, and the median left ventricular ejection fraction was 63%. A total of 22 patients received pacemaker implantation, including 17 (77.3%) dual-chamber pacing, four (18.2%) single-chamber ventricular pacing, and one (4.5%) cardiac resynchronization therapy. Conclusions: Primary bradyarrhythmias need to be evaluated in HCM patients with arrhythmia-related symptoms. Patients with HCM might need pacemaker implantation for primary bradyarrhythmias.
Collapse
|
26
|
Reply: Long-Term Mortality in Obstructive Hypertrophic Cardiomyopathy: Looking Beyond the Assigned Treatment. J Am Coll Cardiol 2022; 80:e89. [PMID: 36075685 DOI: 10.1016/j.jacc.2022.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/21/2022]
|
27
|
Maron BJ, Dearani JA, Smedira NG, Schaff HV, Wang S, Rastegar H, Ralph-Edwards A, Ferrazzi P, Swistel D, Shemin RJ, Quintana E, Bannon PG, Shekar PS, Desai M, Roberts WC, Lever HM, Adler A, Rakowski H, Spirito P, Nishimura RA, Ommen SR, Sherrid MV, Rowin EJ, Maron MS. Ventricular Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy (Analysis Spanning 60 Years Of Practice): AJC Expert Panel. Am J Cardiol 2022; 180:124-139. [PMID: 35965115 DOI: 10.1016/j.amjcard.2022.06.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 05/23/2022] [Accepted: 06/06/2022] [Indexed: 12/15/2022]
Abstract
Surgical myectomy remains the time-honored primary treatment for hypertrophic cardiomyopathy patients with drug refractory limiting symptoms due to LV outflow obstruction. Based on >50 years experience, surgery reliably reverses disabling heart failure by permanently abolishing mechanical outflow impedance and mitral regurgitation, with normalization of LV pressures and preserved systolic function. A consortium of 10 international currently active myectomy centers report about 11,000 operations, increasing significantly in number over the most recent 15 years. Performed in experienced multidisciplinary institutions, perioperative mortality for myectomy has declined to 0.6%, becoming one of the safest currently performed open-heart procedures. Extended myectomy relieves symptoms in >90% of patients by ≥ 1 NYHA functional class, returning most to normal daily activity, and also with a long-term survival benefit; concomitant Cox-Maze procedure can reduce the number of atrial fibrillation episodes. Surgery, preferably performed in high volume clinical environments, continues to flourish as a guideline-based and preferred high benefit: low treatment risk option for adults and children with drug refractory disabling symptoms from obstruction, despite prior challenges: higher operative mortality/skepticism in 1960s/1970s; dual-chamber pacing in 1990s, alcohol ablation in 2000s, and now introduction of strong negative inotropic drugs potentially useful for symptom management.
Collapse
Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA.
| | | | | | | | | | | | | | | | | | | | | | | | - Prem S Shekar
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA
| | | | - William C Roberts
- Department of Pathology and Medicine; Baylor UniversityMedical Center, Dallas Texas
| | | | - Arnon Adler
- Toronto General Hospital, Toronto Ontario, Canada
| | | | | | | | | | | | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA
| |
Collapse
|
28
|
Zhu H, Wang Z, Li X, Yao Y, Huang W, Liu Z, Fan X. The Initial Experience of Left Bundle Branch Area Pacing in Patients with Hypertrophic Cardiomyopathy. Pacing Clin Electrophysiol 2022; 45:1065-1074. [PMID: 35895634 DOI: 10.1111/pace.14563] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/20/2022] [Accepted: 07/01/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Whether Left bundle branch area pacing (LBBAP) could be achieved in patients with hypertrophic cardiomyopathy (HCM) requiring ventricular pacing remains unknown. The present study aimed to investigate the feasibility and effect of LBBAP in HCM. METHODS Patients with HCM who underwent LBBAP were recruited from November 2018 to September 2021. Clinical characteristics, echocardiographic, and pacing parameters were prospectively collected at baseline and during follow-up. RESULTS Eleven consecutive HCM patients who attempted LBBAP were included (mean age 64.0±8.7 years, female 45.5%, mean interventricular septum 16.7mm). The success rate of LBBAP was 36.4% (4/11) and the reason for failed LBBAP in other 7 HCM patients was the inability to screw the lead into the deep septum or capture the left bundle branch. Patients with successful LBBAP had significantly narrower QRS duration than those with failed (118.0 ± 3.7 ms vs. 140.9 ± 9.4 ms, p = 0.01) while the capture thresholds, sensing amplitudes, and pacing impedances were similar. Successful cases presented with less positive late gadolinium enhancement (25.0% vs. 71.4%, p = 0.02) and thinner interventricular thickness (14.5 ± 1.0 mm vs. 18.0 ± 2.5 mm, p = 0.02) when compared with failed cases. Pacing parameters remained stable and no procedure-related complications occurred during a mean follow-up of 8.9 ± 7.3 months. CONCLUSION LBBAP may be successfully achieved in less than half of HCM patients due to thick interventricular septum and heavy burden of myocardial fibrosis. Pacing strategies should be cautiously considered in patients with HCM. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Haojie Zhu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhao Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaofei Li
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Yao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weijian Huang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhimin Liu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohan Fan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
29
|
Lawin D, Lawrenz T, Marx K, Danielsmeier NB, Poudel MR, Stellbrink C. Gender disparities in alcohol septal ablation for hypertrophic obstructive cardiomyopathy. Heart 2022; 108:1623-1628. [PMID: 35697495 DOI: 10.1136/heartjnl-2022-320852] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 05/20/2022] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Alcohol septal ablation (ASA) improves symptoms in hypertrophic obstructive cardiomyopathy (HOCM). We conducted a large retrospective analysis investigating gender effects on outcome after ASA. METHODS AND RESULTS 1367 ASAs between 2002 and 2020 were analysed. Women (47.2%) were older (66.0 years (IQR 55.0-74.0) vs 54.0 years (IQR 45.0-62.0); p<0.0001) with more severe symptoms. The interventricular septal diameter (IVSD) was higher in men (21.0 mm (IQR 19.0-24.0) vs 20.0 mm (IQR 18.0-23.0); p<0.0001) but the IVSD indexed to body surface area was higher in women (10.9 mm/m2 (IQR 9.7-12.7) vs 10.2 mm/m2 (IQR 9.0-11.7); p<0.0001). Women had lower exercise-induced left ventricular outflow tract gradients (LVOTG) 1-4 days after ASA (55.0 mm Hg (IQR 30.0-109.0) vs 71.0 mm Hg (IQR 37.0-115.0); p=0.0006). There was a trend for lower resting LVOTG 1-4 days after ASA (20.0 mm Hg (IQR 12.0-37.5) vs 22.0 mm Hg (IQR 13.0-40.0); p=0.0062) and lower exercise-induced LVOTG after 6 months in women (34.0 mm Hg (IQR 21.0-70.0) vs 43.5 mm Hg (IQR 25.0-74.8); p=0.0072), but this was not statistically significant after Bonferroni correction. More women developed atrioventricular (AV) block (20.3% vs 13.3%; p=0.0005) and required a pacemaker (17.4% vs 10.4%; p=0.0002) but not a cardioverter defibrillator (9.0% vs 11.6% in men; p=n .s.). However, in multivariable regression models, there was no evidence that sex independently influenced LVOTG and the occurrence of AV block. CONCLUSION Female patients with HOCM were older and had more advanced disease at the time of ASA. Women had superior short-term haemodynamic response to ASA but more often developed AV block after ASA. These results are important to consider for sex-specific counselling before ASA.
Collapse
Affiliation(s)
- Dennis Lawin
- Cardiology and Intensive Care Medicine, University Hospital OWL of Bielefeld University, Campus Klinikum Bielefeld, Bielefeld, Germany
| | - Thorsten Lawrenz
- Cardiology and Intensive Care Medicine, University Hospital OWL of Bielefeld University, Campus Klinikum Bielefeld, Bielefeld, Germany.,Faculty of Health, University Witten Herdecke, Witten, Germany
| | - Kristin Marx
- Cardiology and Intensive Care Medicine, University Hospital OWL of Bielefeld University, Campus Klinikum Bielefeld, Bielefeld, Germany
| | - Nils Benedikt Danielsmeier
- Cardiology and Intensive Care Medicine, University Hospital OWL of Bielefeld University, Campus Klinikum Bielefeld, Bielefeld, Germany
| | - Madan Raj Poudel
- Cardiology and Intensive Care Medicine, University Hospital OWL of Bielefeld University, Campus Klinikum Bielefeld, Bielefeld, Germany
| | - Christoph Stellbrink
- Cardiology and Intensive Care Medicine, University Hospital OWL of Bielefeld University, Campus Klinikum Bielefeld, Bielefeld, Germany
| |
Collapse
|
30
|
Cui H, Schaff HV, Wang S, Lahr BD, Rowin EJ, Rastegar H, Hu S, Eleid MF, Dearani JA, Kimmelstiel C, Maron BJ, Nishimura RA, Ommen SR, Maron MS. Survival Following Alcohol Septal Ablation or Septal Myectomy for Patients With Obstructive Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2022; 79:1647-1655. [PMID: 35483751 DOI: 10.1016/j.jacc.2022.02.032] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is little information regarding long-term mortality comparing the 2 most common procedures for septal reduction for obstructive hypertrophic cardiomyopathy (HCM), alcohol septal ablation (ASA), and septal myectomy. OBJECTIVES This study sought to compare the long-term mortality of patients with obstructive HCM following septal myectomy or ASA. METHODS We evaluated outcomes of 3,859 patients who underwent ASA or septal myectomy in 3 specialized HCM centers. All-cause mortality was the primary endpoint of the study. RESULTS In the study cohort, 585 (15.2%) patients underwent ASA, and 3,274 (84.8%) underwent septal myectomy. Patients undergoing ASA were significantly older (median age: 63.0 years [IQR: 52.7-72.8 years] vs 53.7 years [IQR: 44.9-62.8 years]; P < 0.001) and had smaller septal thickness (19.0 mm [IQR: 17.0-22.0 mm] vs 20.0 mm [IQR: 17.0-23.0 mm]; P = 0.007). Patients undergoing ASA also had more comorbidities, including renal failure, diabetes, hypertension, and coronary artery disease. There were 4 (0.7%) early deaths in the ASA group and 9 (0.3%) in the myectomy group. Over a median follow-up of 6.4 years (IQR: 3.6-10.2 years), the 10-year all-cause mortality rate was 26.1% in the ASA group and 8.2% in the myectomy group. After adjustment for age, sex, and comorbidities, the mortality remained greater in patients having septal reduction by ASA (HR: 1.68; 95% CI: 1.29-2.19; P < 0.001). CONCLUSIONS In patients with obstructive hypertrophic cardiomyopathy, ASA is associated with increased long-term all-cause mortality compared with septal myectomy. This impact on survival is independent of other known factors but may be influenced by unmeasured confounding patient characteristics.
Collapse
Affiliation(s)
- Hao Cui
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA.
| | - Shuiyun Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Brian D Lahr
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Ethan J Rowin
- Division of Cardiology, Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Hassan Rastegar
- Division of Cardiothoracic Surgery, Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Shengshou Hu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Carey Kimmelstiel
- Division of Cardiology, Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Barry J Maron
- Division of Cardiology, Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Steve R Ommen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Martin S Maron
- Division of Cardiology, Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
31
|
2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Translation of the document prepared by the Czech Society of Cardiology. COR ET VASA 2022. [DOI: 10.33678/cor.2022.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
32
|
Anumolu AR, Anumolu A, Kumar S. Letter to the Editor: Early and midterm results of extended septal myectomy: Indian experience. J Card Surg 2022; 37:1460-1461. [PMID: 35212426 DOI: 10.1111/jocs.16368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 02/18/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Akhil R Anumolu
- Department of Internal Medicine, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
| | - Aakash Anumolu
- Department of Internal Medicine, Bukovinian State Medical University, Chernvtsi, Ukraine
| | - Satesh Kumar
- Department of Internal Medicine, Shaheed Mohtarma Benazir Bhutto Medical College Liyari, Karachi, Pakistan
| |
Collapse
|
33
|
Mitra S, Ramanathan K, MacLaren G. Post-operative management of hypertrophic obstructive cardiomyopathy. Asian Cardiovasc Thorac Ann 2022; 30:57-63. [PMID: 35167344 DOI: 10.1177/02184923211069189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hypertrophic obstructive cardiomyopathy patients are at increased risk of sudden cardiac arrest due to dynamic left ventricular outflow tract obstruction, myocardial ischaemia and arrhythmias. Septal myectomy remains the gold standard therapy for patients with hypertrophic obstructive cardiomyopathy (HOCM) refractory to other therapy. This review comprehensively focuses on the post-operative management and complications of HOCM patients undergoing surgical correction. Although these patients are at risk of various perioperative complications from anaesthesia and surgery due to the underlying complexity of their disease, surgical myectomy is associated with excellent long-term outcomes if carried out in experienced centers.
Collapse
Affiliation(s)
- Saikat Mitra
- Department of Intensive Care, 3187Lyell McEwin Hospital, Adelaide, Australia
| | - Kollengode Ramanathan
- Department of Cardiac, Thoracic, and Vascular Surgery, Cardiothoracic ICU, National University Hospital, Singapore, Singapore
| | - Graeme MacLaren
- Department of Cardiac, Thoracic, and Vascular Surgery, Cardiothoracic ICU, National University Hospital, Singapore, Singapore
| |
Collapse
|
34
|
Maron BJ, Desai MY, Nishimura RA, Spirito P, Rakowski H, Towbin JA, Dearani JA, Rowin EJ, Maron MS, Sherrid MV. Management of Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2022; 79:390-414. [DOI: 10.1016/j.jacc.2021.11.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/28/2021] [Accepted: 11/02/2021] [Indexed: 01/14/2023]
|
35
|
Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJ, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. Grupo de trabajo sobre estimulación cardiaca y terapia de resincronización cardiaca de la Sociedad Europea de Cardiología (ESC). Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
36
|
Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM, Leyva F, Linde C, Abdelhamid M, Aboyans V, Arbelo E, Asteggiano R, Barón-Esquivias G, Bauersachs J, Biffi M, Birgersdotter-Green U, Bongiorni MG, Borger MA, Čelutkienė J, Cikes M, Daubert JC, Drossart I, Ellenbogen K, Elliott PM, Fabritz L, Falk V, Fauchier L, Fernández-Avilés F, Foldager D, Gadler F, De Vinuesa PGG, Gorenek B, Guerra JM, Hermann Haugaa K, Hendriks J, Kahan T, Katus HA, Konradi A, Koskinas KC, Law H, Lewis BS, Linker NJ, Løchen ML, Lumens J, Mascherbauer J, Mullens W, Nagy KV, Prescott E, Raatikainen P, Rakisheva A, Reichlin T, Ricci RP, Shlyakhto E, Sitges M, Sousa-Uva M, Sutton R, Suwalski P, Svendsen JH, Touyz RM, Van Gelder IC, Vernooy K, Waltenberger J, Whinnett Z, Witte KK. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Europace 2022; 24:71-164. [PMID: 34455427 DOI: 10.1093/europace/euab232] [Citation(s) in RCA: 137] [Impact Index Per Article: 68.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
|
37
|
Francia P, Olivotto I, Lambiase PD, Autore C. Implantable cardioverter-defibrillators for hypertrophic cardiomyopathy: The Times They Are a-Changin'. Europace 2021; 24:1384-1394. [PMID: 34966939 DOI: 10.1093/europace/euab309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 12/01/2021] [Indexed: 11/14/2022] Open
Abstract
The implantable cardioverter-defibrillator (ICD) is a life-saving therapy in patients with hypertrophic cardiomyopathy (HCM) at high risk of sudden cardiac death. The heterogeneity of clinical scenarios in HCM and the availability of ICDs with distinct characteristics emphasizes the need for selecting the right device for the right patient. There is growing awareness that unnecessarily complex devices can lead to short- and long-term complications without adding significant clinical benefits. Young patients have the greatest potential years of life gained from the ICD but are also most exposed to device-related complications. This increases the complexity of decision-making of ICD prescription in these often otherwise well patients in whom device selection should be tailored to preserve survival benefit without introducing morbidity. In the light of the multiple clinical phenotypes characterizing HCM, the present article offers evidence-based perspectives helpful in predicting the individual impact of the ICD and choosing the most appropriate device.
Collapse
Affiliation(s)
- Pietro Francia
- Division of Cardiology, Department of Clinical and Molecular Medicine, St. Andrea Hospital, Sapienza University, Rome, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital. Dept of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Pier D Lambiase
- Institute of Cardiovascular Science, UCL Department of Cardiology, Barts Heart Centre, London, UK
| | - Camillo Autore
- Division of Cardiology, Department of Clinical and Molecular Medicine, St. Andrea Hospital, Sapienza University, Rome, Italy
| |
Collapse
|
38
|
Shalen EF, Heitner SB, Al-Rashdan L, Akhavein R, Elman MR, Fischer KL, Lin LQ, Mannello M, Nazer B, Song HK, Masri A. Perioperative Amiodarone to Prevent Atrial fibrillation after Septal Myectomy in obstrUctive hypeRtroPHic cardiomyopathy. ESC Heart Fail 2021; 8:4791-4799. [PMID: 34708572 PMCID: PMC8712783 DOI: 10.1002/ehf2.13662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 09/11/2021] [Accepted: 09/28/2021] [Indexed: 11/11/2022] Open
Abstract
Aims Amiodarone reduces the incidence of atrial fibrillation (AF) following coronary artery bypass surgery; however, the benefit of perioperative amiodarone in patients undergoing septal myectomy (SM) for obstructive hypertrophic cardiomyopathy (oHCM) has not been studied. We hypothesized that prophylactic amiodarone would reduce the incidence of postoperative AF (POAF) following SM for oHCM. Methods and Results A single‐centre, pre‐post intervention open‐label study of oral amiodarone (200 mg twice daily starting 7 days preoperatively and 200 mg once daily continuing for 30 days postoperatively) in patients without prior AF undergoing SM for oHCM from 2014 to 2018. The primary outcome was incident AF within 30 days. Secondary outcomes were unplanned readmission, AF treatment, total and intensive care unit (ICU) length of stay (LOS), and pacemaker implantation for high‐grade atrioventricular (AV) block. 61 patients met inclusion criteria with 34 (55.8%) in the pre‐intervention (control) group and 27 (44.2%) in the post‐intervention (amiodarone) group. The incidence of POAF was 11.0% in the amiodarone group compared with 38.2% in the control group (P = 0.017). After adjusting for age, amiodarone was associated with less POAF [adjusted odds ratio (aOR) 0.21; 95% confidence interval (CI) 0.05, 0.76; P = 0.016]. ICU (2 days [IQR 1, 4] vs. 3 days [IQR 2, 4]; P = 0.165) and total (6 days [IQR 5, 6] vs. 6 days [IQR 5, 7]; P = 0.165) LOS were similar, as was the rate of pacemaker implantation (7.4% vs. 8.3%, P > 0.999). There were no adverse events associated with amiodarone. Conclusions Perioperative oral amiodarone is safe and was associated with lower incidence of POAF following SM for oHCM.
Collapse
Affiliation(s)
- Evan F Shalen
- The Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Stephen B Heitner
- The Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Lana Al-Rashdan
- The Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Reyhaneh Akhavein
- The Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Miriam R Elman
- School of Public Health, Oregon Health & Science University, Portland State University, Portland, Oregon, USA
| | - Katherine L Fischer
- The Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Lucy Q Lin
- The Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Meghan Mannello
- The Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Babak Nazer
- The Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Howard K Song
- The Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Ahmad Masri
- The Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
39
|
Left Bundle Branch Block: Characterization, Definitions, and Recent Insights into Conduction System Physiology. Card Electrophysiol Clin 2021; 13:671-684. [PMID: 34689894 DOI: 10.1016/j.ccep.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Left bundle branch block (LBBB) is not just a simple electrocardiogram alteration. The intricacies of this general terminology go beyond simple conduction block. This review puts together current knowledge on the historical concept of LBBB, clinical significance, and recent insights into the pathophysiology of human LBBB. LBBB is an entity that affects patient diagnosis (primary conduction disease, secondary to underlying pathology or iatrogenic), treatment (cardiac resynchronization therapy or conduction system pacing for heart failure), and prognosis. Recruiting the left bundle branch with conduction system pacing depends on the complex interaction between anatomy, site of pathophysiology, and delivery tools.
Collapse
|
40
|
Pelliccia F, Seggewiss H, Cecchi F, Calabrò P, Limongelli G, Alfieri O, Ferrazzi P, Yacoub MH, Olivotto I. Septal Ablation Versus Surgical Myomectomy for Hypertrophic Obstructive Cardiomyopathy. Curr Cardiol Rep 2021; 23:165. [PMID: 34599387 PMCID: PMC8486700 DOI: 10.1007/s11886-021-01600-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW Patients with hypertrophic cardiomyopathy (HCM) who have left ventricular outflow tract obstruction (LVOTO) often experience severe symptoms and functional limitation. Relief of LVOTO can be achieved by two invasive interventions, i.e., surgery myectomy and alcohol septal ablation (ASA), leading in experienced hands to a dramatic improvement in clinical status. Despite extensive research, however, the choice of the best option in individual patients remains challenging and poses numerous clinical dilemmas. RECENT FINDINGS Invasive strategies have been recently incorporated in recommendations for the diagnosis and treatment of HCM on both sides of the Atlantic. These guidelines are based on a bulk of well-designed but retrospective studies as well as on expert opinions. Evidence now exists that adequate evaluation and management of HCM requires a multidisciplinary team capable of choosing the best available options. Management of LVOTO still varies largely based on local expertise and patient preference. Following the trend that has emerged for other cardiac diseases amenable to invasive interventions, the concept of a "HCM heart team" is coming of age.
Collapse
Affiliation(s)
- F Pelliccia
- Department of Cardiovascular Sciences, University Sapienza, Via del Policlinico 155, 00161, Rome, Italy.
| | - H Seggewiss
- Comprehensive Heart Failure Center (CHFC), Deutsches Zentrum Für Herzinsuffizienz (DZHI), Universitätsklinikum Würzburg, Würzburg, Germany
| | - F Cecchi
- Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, San Luca Hospital, Milan, Italy
| | - P Calabrò
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - G Limongelli
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy.,Institute of Cardiovascular Sciences, University College of London, St. Bartholomew's Hospital, London, UK
| | - O Alfieri
- Department of Cardiovascular and Thoracic Surgery, San Raffaele University Hospital, Milan, Italy
| | - P Ferrazzi
- Hypertrophic Cardiomyopathy Center, Policlinico Di Monza, Monza, Italy
| | - M H Yacoub
- Heart Science Centre, National Heart and Lung Institute, Imperial College London, London, UK
| | - I Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| |
Collapse
|
41
|
Ji Q, Wang Y, Liu F, Yang Y, Xia L, Ding W, Lai H, Wang C. Hypertrophic cardiomyopathy with latent obstruction: Clinical characteristics and surgical results. J Cardiol 2021; 79:42-49. [PMID: 34551867 DOI: 10.1016/j.jjcc.2021.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/06/2021] [Accepted: 08/28/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The role of mitral subvalvular anomalies in the etiology of latent left ventricular outflow tract (LVOT) obstruction has rarely been reported; and the results of surgical treatment for latent LVOT obstruction have been infrequently reported as a separate group by other medical centers other than Mayo clinic. METHODS Among 292 eligible patients, 45 with resting gradients <30 mmHg had provoked obstruction. Their clinical characteristics and surgical results were compared with those of 247 patients with resting LVOT obstruction. The patients were followed up for a median of 13 months. RESULTS Comparatively, patients with latent obstruction were younger (51.6±12.1 years vs. 57.2±11.6 years, p=0.003) and had higher prevalence of mitral subvalvular abnormalities (73.3% vs. 16.2%, p<0.001) and basal variant of hypertrophic cardiomyopathy (84.5% vs. 62.0%, p=0.014), less marked septal thickness (16.9±2.8 mm vs. 18.6±3.8 mm, p=0.005), lower resting gradients (22.2±5.7 mmHg vs. 93.0±25.7 mmHg, p < 0.001), and lower mitral regurgitation severity (median, 2.0 vs. 3.0, p<0.001). After surgery, no surgical death occurred in patients with latent LVOT obstruction. Only one (2.2%) patient from the latent group developed complete atrioventricular block. No follow-up death or reoperation was recorded with a significant improvement in New York Heart Association functional status in either group. The provoked LVOT gradients of patients with latent obstruction decreased sharply from the preoperative value (11.8±3.7 mmHg vs. 89.8±16.4 mmHg, p < 0.001), with no occurrence of residual obstruction. CONCLUSIONS Symptomatic patients with latent LVOT obstruction may have a higher prevalence of mitral subvalvular abnormalities and have less marked septal hypertrophy; and concomitant mitral management during myectomy for the treatment of this patient group achieved excellent results.
Collapse
Affiliation(s)
- Qiang Ji
- Department of Cardiovascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China
| | - YuLin Wang
- Department of Cardiovascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China
| | - FangYu Liu
- Department of Cardiovascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China
| | - Ye Yang
- Department of Cardiovascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China
| | - LiMin Xia
- Department of Cardiovascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China
| | - WenJun Ding
- Department of Cardiovascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China
| | - Hao Lai
- Department of Cardiovascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China.
| | - ChunSheng Wang
- Shanghai Municipal Institute for Cardiovascular Diseases, 1609 Xietu Road, Shanghai 200032, China.
| |
Collapse
|
42
|
Kumar N, Kanna S, Goel H, Mohanty A, Mohan R, Dubey S, Shad S. Early and midterm results of extended septal myectomy: Indian experience. J Card Surg 2021; 36:4465-4471. [PMID: 34532892 DOI: 10.1111/jocs.15977] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/15/2021] [Accepted: 08/27/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder, which is a cause of significant morbidity and sudden cardiac death. Extended septal myectomy (ESM) is the therapeutic gold standard to treat left ventricular outflow tract obstruction (LVOTO) in HOCM resulting in long-term symptomatic relief. The aim of the study was to assess the impact of ESM on midterm symptom relief, LVOTO, and survival in patients suffering from HOCM in the Indian population. METHODS We retrospectively analyzed clinical data of 36 consecutive symptomatic patients with HOCM having symptoms refractory to medical treatment and LVOTO with resting gradient ≥ 50 mmHg and who underwent ESM at our institution from 2010 to 2019. Preoperative and postoperative transthoracic echocardiography was performed to assess left ventricular outflow tract (LVOT) gradient, septal thickness, and assessment of valvar and cardiac function. RESULTS ESM was performed successfully in all 36 patients. The mean preoperative LVOT gradient was 113.06 ± 36.70 mmHg and decreased to 15.17 ± 7.30 mmHg (p < .0001) in the initial postoperative period. There were two in-hospital deaths (5.6%). There was no further mortality in the subsequent follow-up. The mean septal thickness was 23.89 ± 5.77 mm preoperatively and 13.17 ± 3.48 mm (p < .0001) postoperatively. During a mean follow-up of 2 years, the NYHA functional class improved from 3.50 ± 0.70 (III-IV) to 1.50 ± 0.70 (I) (p < .0001). CONCLUSIONS ESM results in immediate abolition of mechanical obstruction to LVOT with normalization of left ventricular pressure and eliminates symptoms associated with HOCM.
Collapse
Affiliation(s)
- Narendra Kumar
- Department of Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Sharmil Kanna
- Department of Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Himanshu Goel
- Department of Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Arun Mohanty
- Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Rajat Mohan
- Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Sumir Dubey
- Department of Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Sujay Shad
- Department of Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India
| |
Collapse
|
43
|
Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2021; 42:3427-3520. [PMID: 34455430 DOI: 10.1093/eurheartj/ehab364] [Citation(s) in RCA: 840] [Impact Index Per Article: 280.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
44
|
Seco M, Lau JC, Medi C, Bannon PG. Atrial fibrillation management during septal myectomy for hypertrophic cardiomyopathy: A systematic review. Asian Cardiovasc Thorac Ann 2021; 30:98-107. [PMID: 34486381 DOI: 10.1177/02184923211042136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Atrial fibrillation is common in patients with hypertrophic cardiomyopathy, and significantly impacts mortality and morbidity. In patients with atrial fibrillation undergoing septal myectomy, concomitant surgery for atrial fibrillation may improve outcomes. METHODS A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies reporting the outcomes of combined septal myectomy and atrial fibrillation surgery were included. RESULTS A total of 10 observational studies were identified, including 644 patients. Most patients had paroxysmal atrial fibrillation. The proportion with prior unsuccessful ablation ranged from 0 to 19%, and preoperative left atrial diameter ranged from 44 ± 17 to 52 ± 8 mm. Cox-Maze IV (n = 311) was the most common technique used, followed by pulmonary vein isolation (n = 222) and Cox-Maze III (n = 98). Patients with persistent or longstanding atrial fibrillation more frequently received Cox-Maze III/IV. Ranges of early postoperative outcomes included: mortality 0 to 7%, recurrence of atrial tachyarrhythmias 4.4 to 48%, cerebrovascular events 0 to 1.5%, and pacemaker insertion 3 to 21%. Long-term data was limited. Freedom from atrial tachyarrhythmias at 1 year ranged from 74% to 96%, and at 5 years from 52% to 100%. Preoperative predictors of late atrial tachyarrhythmia recurrence included left atrial diameter >45 mm, persistent or longstanding preoperative atrial fibrillation and longer atrial fibrillation duration. CONCLUSION In patients with atrial fibrillation undergoing septal myectomy, the addition of ablation surgery adds low overall risk to the procedure, and likely reduces the risk of recurrent atrial fibrillation in the long term. Future randomised studies comparing septal myectomy with or without concomitant AF ablation are needed.
Collapse
Affiliation(s)
- Michael Seco
- Sydney Medical School, 7799University of Sydney, Australia.,The Baird Institute of Applied Heart & Lung Surgical Research, Australia.,Department of Cardiothoracic Surgery, 2205Royal Prince Alfred Hospital, Australia
| | - Jonathan Cl Lau
- Sydney Medical School, 7799University of Sydney, Australia.,The Baird Institute of Applied Heart & Lung Surgical Research, Australia
| | - Caroline Medi
- Sydney Medical School, 7799University of Sydney, Australia.,Department of Cardiology, 2205Royal Prince Alfred Hospital, Australia
| | - Paul G Bannon
- Sydney Medical School, 7799University of Sydney, Australia.,The Baird Institute of Applied Heart & Lung Surgical Research, Australia.,Department of Cardiothoracic Surgery, 2205Royal Prince Alfred Hospital, Australia
| |
Collapse
|
45
|
Ommen SR, Mital S, Burke MA, Day SM, Deswal A, Elliott P, Evanovich LL, Hung J, Joglar JA, Kantor P, Kimmelstiel C, Kittleson M, Link MS, Maron MS, Martinez MW, Miyake CY, Schaff HV, Semsarian C, Sorajja P, O'Gara PT, Beckman JA, Levine GN, Al-Khatib SM, Armbruster A, Birtcher KK, Ciggaroa J, Dixon DL, de Las Fuentes L, Deswal A, Fleisher LA, Gentile F, Goldberger ZD, Gorenek B, Haynes N, Hernandez AF, Hlatky MA, Joglar JA, Jones WS, Marine JE, Mark D, Palaniappan L, Piano MR, Tamis-Holland J, Wijeysundera DN, Woo YJ. 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e23-e106. [PMID: 33926766 DOI: 10.1016/j.jtcvs.2021.04.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
46
|
Cui H, Schaff HV, Lentz Carvalho J, Nishimura RA, Geske JB, Dearani JA, Lahr BD, Lee AT, Bos JM, Ackerman MJ, Ommen SR, Maleszewski JJ. Myocardial Histopathology in Patients With Obstructive Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2021; 77:2159-2170. [PMID: 33926651 DOI: 10.1016/j.jacc.2021.03.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is characterized by multiple pathological features including myocyte hypertrophy, myocyte disarray, and interstitial fibrosis. OBJECTIVES This study sought to correlate myocardial histopathology with clinical characteristics of patients with obstructive HCM and post-operative outcomes following septal myectomy. METHODS The authors reviewed the pathological findings of the myocardial specimens from 1,836 patients with obstructive HCM who underwent septal myectomy from 2000 to 2016. Myocyte hypertrophy, myocyte disarray, interstitial fibrosis, and endocardial thickening were graded and analyzed. RESULTS The median age at operation was 54.2 years (43.5 to 64.3 years), and 1,067 (58.1%) were men. A weak negative correlation between myocyte disarray and age at surgery was identified (ρ = -0.22; p < 0.001). Myocyte hypertrophy (p < 0.001), myocyte disarray (p < 0.001), and interstitial fibrosis (p < 0.001) were positively associated with implantable cardioverter-defibrillator implantation. Interstitial fibrosis (p < 0.001) and endocardial thickening (p < 0.001) were associated with atrial fibrillation pre-operatively. In the Cox survival model, older age (p < 0.001), lower degree of myocyte hypertrophy (severe vs. mild hazard ratio: 0.41; 95% confidence interval: 0.19 to 0.86; p = 0.040), and lower degree of endocardial thickening (moderate vs. mild hazard ratio: 0.75; 95% confidence interval: 0.58 to 0.97; p = 0.019) were independently associated with worse post-myectomy survival. Among 256 patients who had genotype analysis, patients with pathogenic or likely pathogenic variants (n = 62) had a greater degree of myocyte disarray (42% vs. 15% vs. 20%; p = 0.022). Notably, 13 patients with pathogenic or likely pathogenic genetic variants of HCM had no myocyte disarray. CONCLUSIONS Histopathology was associated with clinical manifestations including the age of disease onset and arrhythmias. Myocyte hypertrophy and endocardial thickening were negatively associated with post-myectomy mortality.
Collapse
Affiliation(s)
- Hao Cui
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA.
| | | | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey B Geske
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian D Lahr
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander T Lee
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - J Martijn Bos
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Ackerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Steve R Ommen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph J Maleszewski
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
47
|
Ji Q, Wang Y, Yang Y, Xia L, Qi X, Wang C. Septuagenarians with hypertrophic obstructive cardiomyopathy undergoing myectomy: the experience of a single center. Surg Today 2021; 51:1471-1479. [PMID: 33846839 DOI: 10.1007/s00595-021-02272-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/04/2021] [Indexed: 11/30/2022]
Abstract
PURPOSES A previous study reported that the ventricular septum is more fragile in geriatric patients, and thus myectomy may expose geriatric patients to a higher risk of serious complications. This single-center study evaluates the impacts of the advanced age on the results following myectomy for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). METHODS All eligible patients were divided into an elderly group (septuagenarians, n = 35) and a control group (patients under 70 years, n = 197). The patients were followed up for a median of 10 months. Thereafter, the perioperative and follow-up results were compared. RESULTS Thirteen patients (8.6% for the elderly group and 5.1% for the control group, p = 0.422) underwent immediate repeat surgery. Surgical mortality did not differ between groups (0 vs. 0.5%, p > 0.05). There was no significant difference in the incidence of complete atrioventricular block between groups (5.7 vs. 3.0%, p = 0.346). No follow-up deaths occurred in either group. The maximum gradients at the latest follow-up were significantly lower than the preoperative values in either group. Additionally, grouping (septuagenarians vs. patients under 70 years of age) was not an independent risk factor for surgical complications and results via multivariable logistic regression. CONCLUSIONS Septuagenarians with HOCM may obtain favorable results following septal myectomy, the same as did HOCM patients under 70 years of age.
Collapse
Affiliation(s)
- Qiang Ji
- Department of Cardiovascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - YuLin Wang
- Department of Cardiovascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Ye Yang
- Department of Cardiovascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - LiMin Xia
- Department of Cardiovascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.,Department of Cardiovascular Surgery of Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China
| | - XiaoMin Qi
- Department of Cardiovascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
| | - ChunSheng Wang
- Shanghai Municipal Institute for Cardiovascular Diseases, 1609 Xietu Road, Shanghai, 200032, China.
| |
Collapse
|
48
|
Lawin D, Lawrenz T, Radke K, Wolff A, Stellbrink C. Alcohol-induced right bundle branch block is associated with a benign outcome in HOCM after alcohol septum ablation (ASA). Clin Res Cardiol 2021; 111:175-185. [PMID: 33772362 DOI: 10.1007/s00392-021-01847-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Alcohol septum ablation (ASA) is a treatment option for hypertrophic obstructive cardiomyopathy (HOCM). We examined the impact of ASA-induced bundle branch block (BBB) on clinical and hemodynamic features. METHODS AND RESULTS We retrospectively analysed 98 HOCM patients with regard to ASA-induced BBB. Clinical examination was performed at baseline, early after ASA and at chronic follow-up (FU). ASA reduced left ventricular outflow tract gradient (LVOTG) during chronic FU (69.2 ± 41.6 pre vs. 31.8 ± 30.3 mmHg post ASA; p < 0.05) and interventricular septal diameter (21.7 ± 3.4 pre vs. 18.7 ± 5.0 mm post ASA; p < 0.05). ASA-induced early right BBB (RBBB) until discharge was observed in 44.9% and chronic RBBB at FU in 32.7%. Left BBB (LBBB) occurred in 13.3% early after ASA and in only 4.1% at chronic FU. Chronic RBBB was associated with more pronounced exercise-induced LVOTG reduction (102.1 ± 55.2 with vs. 73.6 ± 60.0 mmHg without; p < 0.05). 6-min-walk-test (6-MWT) and NYHA class were not affected by RBBB. LBBB had no influence on LVOTG, 6-MWT and symptoms. More ethanol was injected in patients with early RBBB (1.1 ± 0.4 vs. 0.8 ± 0.3 ml without; p < 0.05), who also showed higher mean CK release (827 ± 341 vs. 583 ± 279 U/l without; p < 0.05). Pacemaker implantation during FU was necessary in 11.5% of patients with early RBBB, 3.1% with chronic RBBB, 7.7% with early LBBB and 0% with chronic LBBB (p = n.s. for BBB vs. no BBB). CONCLUSION ASA-induced RBBB is associated with a higher volume of infused ethanol and higher maximum CK release. RBBB does not adversely affect the clinical outcome or need for pacemaker implantation but was associated with higher exercise-induced LVOTG reduction during chronic FU.
Collapse
Affiliation(s)
- Dennis Lawin
- Department of Cardiology and Intensive Care Medicine, Klinikum Bielefeld gemGmbH, Teutoburger Straße 50, 33604, Bielefeld, Germany
| | - Thorsten Lawrenz
- Department of Cardiology and Intensive Care Medicine, Klinikum Bielefeld gemGmbH, Teutoburger Straße 50, 33604, Bielefeld, Germany.,Faculty of Health, University of Witten/Herdecke, Alfred Herrenhausen Straße 50, 58455, Witten, Germany
| | - Kristin Radke
- Department of Cardiology and Intensive Care Medicine, Klinikum Bielefeld gemGmbH, Teutoburger Straße 50, 33604, Bielefeld, Germany
| | - Andreas Wolff
- Cardiology, Forum Salinum, Salinenstraße 4, 32105, Bad Salzuflen, Germany
| | - Christoph Stellbrink
- Department of Cardiology and Intensive Care Medicine, Klinikum Bielefeld gemGmbH, Teutoburger Straße 50, 33604, Bielefeld, Germany.
| |
Collapse
|
49
|
Sun D, Schaff HV, Nishimura RA, Geske JB, Dearani JA, Lahr BD, Ommen SR. Impact of Body Mass Index on Outcome of Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy. Ann Thorac Surg 2021; 113:519-526. [PMID: 33774005 DOI: 10.1016/j.athoracsur.2021.03.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/19/2021] [Accepted: 03/15/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Obesity is highly prevalent in patients with obstructive hypertrophic cardiomyopathy (HCM). In this study, we investigated the impact of body mass index (BMI) in patients undergoing septal myectomy (SM) for obstructive HCM. METHODS We reviewed 2,746 patients who underwent transaortic SM for obstructive HCM from February 1993 through September 2018. Patients were stratified into 3 groups based on BMI (normal weight < 25 kg/m2, overweight 25 to < 30 kg/m2, and obese ≥ 30 kg/m2). RESULTS Preoperatively, median left ventricular outflow tract (LVOT) gradient was 58 mmHg, and there was no difference in gradients across BMI strata (P=0.35). Obese patients had lower percentage with moderate or greater mitral valve regurgitation (45.8%) compared to normal (52.9%) and overweight (55.4%) patients (P<0.001). However, patients with higher BMI were more likely to have New York Heart Association class III/IV limitation at presentation (P<0.001). After myectomy, both anteroseptal thickness (P=0.115) and LVOT gradient (P=0.210) did not differ between groups. There were 14 (0.5%) deaths < 30 days postoperatively and the risk was similar across BMI strata (P=0.448). Model-estimated changes in average BMI at 10 years post procedure showed stratum-specific increases ranging from 0.60 to 1.56 kg/m2. During a median (IQR) follow-up of 7.2 (3.2-13.3) years, higher BMI was associated with reduced survival after adjusting for baseline covariates (P=0.001). CONCLUSIONS Septal myectomy is safe and effective in HCM patients with obesity, but risk of late mortality increased with increasing BMI. Attention to risk factor management through weight loss may improve late results after SM.
Collapse
Affiliation(s)
- Daokun Sun
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey B Geske
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Brian D Lahr
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Steve R Ommen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
50
|
Yang Q, Zhu C, Cui H, Tang B, Wang S, Yu Q, Zhao S, Song Y, Wang S. Surgical septal myectomy outcome for obstructive hypertrophic cardiomyopathy after alcohol septal ablation. J Thorac Dis 2021; 13:1055-1065. [PMID: 33717578 PMCID: PMC7947546 DOI: 10.21037/jtd-20-2779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Although surgical treatment of residual obstruction after alcohol septal ablation (ASA) is often challenging in patients with obstructive hypertrophic cardiomyopathy (OHCM) there are very few relevant clinical reports. Thus, outcomes of surgical septal myectomy (SSM) in this subgroup of patients remain to be determined. Therefore, this study aimed to determine the surgical and follow-up outcomes in patients with OHCM exhibiting residual obstruction after ASA. Methods We collected case data for 62 patients with OHCM and residual obstruction after ASA who underwent SSM at Fuwai Hospital between January 2002 and June 2019. Propensity score matching with patients having had a myectomy as the only invasive procedure—was conducted in a 1:2 ratio. Echocardiography parameters, surgery results, and follow-up outcomes were compared between the groups. Results The prior ASA group had a higher incidence of complete atrioventricular block (AVB) and subsequently postoperative permanent pacemaker (PPM) implantation than the primary myectomy group (9.7% vs. 1.6%, P=0.01). Two patients died within 30 days after surgery in the prior ASA group, and one patient died in the primary myectomy group, with an operative mortality rate of 3.2% and 0.8%, respectively (P=0.2). The 5-year event-free survival rate was 86.0% in the prior ASA group (median follow-up period: 3.2 years; mean: 3.9±2.6 years; maximum, 10.6 years) and 88.5% in the primary myectomy group (median follow-up period: 2.4 years; mean 2.8±1.7 years; maximum, 9.1 years) (P=0.2). During follow-up, four of 62 (6.5%) patients in the prior ASA group and one of 124 (0.8%) patients in the primary myectomy group progressed to advanced heart failure (P=0.025). Conclusions Patients with OHCM following ASA are at an increased risk of developing AVB after SSM. Their surgical outcomes, and long-term survival rate were satisfactory and, osimilar to those for patients having had a myectomy as the only invasive procedure. In addition, they had an increased risk of advanced heart failure after SSM in the present study.
Collapse
Affiliation(s)
- Qiulan Yang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Changsheng Zhu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Cui
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MI, USA
| | - Bing Tang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University & Beijing Institute of Heart, Beijing, China
| | - Shengwei Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University & Beijing Institute of Heart, Beijing, China
| | - Qinjun Yu
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shihua Zhao
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunhu Song
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuiyun Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|