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Lawrenz T, Lawin D, Stellbrink C. Myosin Inhibitors for Hypertrophic Obstructive Cardiomyopathy (HOCM): Is HOCM Passing Another Crossroads? Can J Cardiol 2024; 40:820-823. [PMID: 38311167 DOI: 10.1016/j.cjca.2024.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 02/10/2024] Open
Affiliation(s)
- Thorsten Lawrenz
- Department of Cardiology and Intensive Care Medicine, University Hospital OWL of Bielefeld University, Campus Klinikum Bielefeld, Bielefeld, Germany.
| | - Dennis Lawin
- Department of Cardiology and Intensive Care Medicine, University Hospital OWL of Bielefeld University, Campus Klinikum Bielefeld, Bielefeld, Germany
| | - Christoph Stellbrink
- Department of Cardiology and Intensive Care Medicine, University Hospital OWL of Bielefeld University, Campus Klinikum Bielefeld, Bielefeld, Germany
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Mariani MV, Pierucci N, Fanisio F, Laviola D, Silvetti G, Piro A, La Fazia VM, Chimenti C, Rebecchi M, Drago F, Miraldi F, Natale A, Vizza CD, Lavalle C. Inherited Arrhythmias in the Pediatric Population: An Updated Overview. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:94. [PMID: 38256355 PMCID: PMC10819657 DOI: 10.3390/medicina60010094] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/17/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024]
Abstract
Pediatric cardiomyopathies (CMs) and electrical diseases constitute a heterogeneous spectrum of disorders distinguished by structural and electrical abnormalities in the heart muscle, attributed to a genetic variant. They rank among the main causes of morbidity and mortality in the pediatric population, with an annual incidence of 1.1-1.5 per 100,000 in children under the age of 18. The most common conditions are dilated cardiomyopathy (DCM) and hypertrophic cardiomyopathy (HCM). Despite great enthusiasm for research in this field, studies in this population are still limited, and the management and treatment often follow adult recommendations, which have significantly more data on treatment benefits. Although adult and pediatric cardiac diseases share similar morphological and clinical manifestations, their outcomes significantly differ. This review summarizes the latest evidence on genetics, clinical characteristics, management, and updated outcomes of primary pediatric CMs and electrical diseases, including DCM, HCM, arrhythmogenic right ventricular cardiomyopathy (ARVC), Brugada syndrome (BrS), catecholaminergic polymorphic ventricular tachycardia (CPVT), long QT syndrome (LQTS), and short QT syndrome (SQTS).
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Affiliation(s)
- Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, “Sapienza” University of Rome, 00161 Rome, Italy; (N.P.); (D.L.); (G.S.); (A.P.); (C.C.); (C.D.V.); (C.L.)
| | - Nicola Pierucci
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, “Sapienza” University of Rome, 00161 Rome, Italy; (N.P.); (D.L.); (G.S.); (A.P.); (C.C.); (C.D.V.); (C.L.)
| | - Francesca Fanisio
- Division of Cardiology, Policlinico Casilino, 00169 Rome, Italy; (F.F.); (M.R.)
| | - Domenico Laviola
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, “Sapienza” University of Rome, 00161 Rome, Italy; (N.P.); (D.L.); (G.S.); (A.P.); (C.C.); (C.D.V.); (C.L.)
| | - Giacomo Silvetti
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, “Sapienza” University of Rome, 00161 Rome, Italy; (N.P.); (D.L.); (G.S.); (A.P.); (C.C.); (C.D.V.); (C.L.)
| | - Agostino Piro
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, “Sapienza” University of Rome, 00161 Rome, Italy; (N.P.); (D.L.); (G.S.); (A.P.); (C.C.); (C.D.V.); (C.L.)
| | - Vincenzo Mirco La Fazia
- Department of Electrophysiology, St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, Austin, TX 78705, USA; (V.M.L.F.); (A.N.)
| | - Cristina Chimenti
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, “Sapienza” University of Rome, 00161 Rome, Italy; (N.P.); (D.L.); (G.S.); (A.P.); (C.C.); (C.D.V.); (C.L.)
| | - Marco Rebecchi
- Division of Cardiology, Policlinico Casilino, 00169 Rome, Italy; (F.F.); (M.R.)
| | - Fabrizio Drago
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital and Research Institute, 00165 Rome, Italy;
| | - Fabio Miraldi
- Cardio Thoracic-Vascular and Organ Transplantation Surgery Department, Policlinico Umberto I Hospital, 00161 Rome, Italy;
| | - Andrea Natale
- Department of Electrophysiology, St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, Austin, TX 78705, USA; (V.M.L.F.); (A.N.)
| | - Carmine Dario Vizza
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, “Sapienza” University of Rome, 00161 Rome, Italy; (N.P.); (D.L.); (G.S.); (A.P.); (C.C.); (C.D.V.); (C.L.)
| | - Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, “Sapienza” University of Rome, 00161 Rome, Italy; (N.P.); (D.L.); (G.S.); (A.P.); (C.C.); (C.D.V.); (C.L.)
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3
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Arbelo E, Protonotarios A, Gimeno JR, Arbustini E, Barriales-Villa R, Basso C, Bezzina CR, Biagini E, Blom NA, de Boer RA, De Winter T, Elliott PM, Flather M, Garcia-Pavia P, Haugaa KH, Ingles J, Jurcut RO, Klaassen S, Limongelli G, Loeys B, Mogensen J, Olivotto I, Pantazis A, Sharma S, Van Tintelen JP, Ware JS, Kaski JP. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J 2023; 44:3503-3626. [PMID: 37622657 DOI: 10.1093/eurheartj/ehad194] [Citation(s) in RCA: 238] [Impact Index Per Article: 238.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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4
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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: 26] [Impact Index Per Article: 13.0] [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.
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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
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5
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Khoche S, Choi C, Kothari P, Hamm K, Poorsattar SP, Maus TM. The Year in Perioperative Echocardiography: Selected Highlights from 2021. J Cardiothorac Vasc Anesth 2022; 36:3459-3468. [DOI: 10.1053/j.jvca.2022.04.002] [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: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 11/11/2022]
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6
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Vriz O, AlSergani H, Elshaer AN, Shaik A, Mushtaq AH, Lioncino M, Alamro B, Monda E, Caiazza M, Mauro C, Bossone E, Al-Hassnan ZN, Albert-Brotons D, Limongelli G. A complex unit for a complex disease: the HCM-Family Unit. Monaldi Arch Chest Dis 2021; 92. [PMID: 34964577 DOI: 10.4081/monaldi.2021.2147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 11/30/2021] [Indexed: 11/23/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a group of heterogeneous disorders that are most commonly passed on in a heritable manner. It is a relatively rare disease around the globe, but due to increased rates of consanguinity within the Kingdom of Saudi Arabia, we speculate a high incidence of undiagnosed cases. The aim of this paper is to elucidate a systematic approach in dealing with HCM patients and since HCM has variable presentation, we have summarized differentials for diagnosis and how different subtypes and genes can have an impact on the clinical picture, management and prognosis. Moreover, we propose a referral multi-disciplinary team HCM-Family Unit in Saudi Arabia and an integrated role in a network between King Faisal Hospital and Inherited and Rare Cardiovascular Disease Unit-Monaldi Hospital, Italy (among the 24 excellence centers of the European Reference Network (ERN) GUARD-Heart). Graphical Abstract.
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Affiliation(s)
- Olga Vriz
- Department of Cardiology, King Faisal Specialist Hospital and Research Center, Riyadh.
| | - Hani AlSergani
- Department of Cardiology, King Faisal Specialist Hospital and Research Center, Riyadh.
| | | | | | | | - Michele Lioncino
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples.
| | - Bandar Alamro
- Department of Cardiology, King Faisal Specialist Hospital and Research Center, Riyadh.
| | - Emanuele Monda
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples.
| | - Martina Caiazza
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples.
| | - Ciro Mauro
- Department of Cardiology, Cardarelli Hospital, Naples.
| | | | - Zuhair N Al-Hassnan
- Cardiovascular Genetics Program and Department of Medical Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh.
| | - Dimpna Albert-Brotons
- Department of Cardiology, King Faisal Specialist Hospital and Research Center, Riyadh.
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples.
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7
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Kitaoka H, Tsutsui H, Kubo T, Ide T, Chikamori T, Fukuda K, Fujino N, Higo T, Isobe M, Kamiya C, Kato S, Kihara Y, Kinugawa K, Kinugawa S, Kogaki S, Komuro I, Hagiwara N, Ono M, Maekawa Y, Makita S, Matsui Y, Matsushima S, Sakata Y, Sawa Y, Shimizu W, Teraoka K, Tsuchihashi-Makaya M, Ishibashi-Ueda H, Watanabe M, Yoshimura M, Fukusima A, Hida S, Hikoso S, Imamura T, Ishida H, Kawai M, Kitagawa T, Kohno T, Kurisu S, Nagata Y, Nakamura M, Morita H, Takano H, Shiga T, Takei Y, Yuasa S, Yamamoto T, Watanabe T, Akasaka T, Doi Y, Kimura T, Kitakaze M, Kosuge M, Takayama M, Tomoike H. JCS/JHFS 2018 Guideline on the Diagnosis and Treatment of Cardiomyopathies. Circ J 2021; 85:1590-1689. [PMID: 34305070 DOI: 10.1253/circj.cj-20-0910] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hiroaki Kitaoka
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University
| | | | - Toru Kubo
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Kyushu University
| | | | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine
| | - Noboru Fujino
- Department of Cardiovascular and Internal Medicine, Kanazawa University, Graduate School of Medical Science
| | - Taiki Higo
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | | | - Chizuko Kamiya
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center
| | - Seiya Kato
- Division of Pathology, Saiseikai Fukuoka General Hospital
| | | | | | | | - Shigetoyo Kogaki
- Department of Pediatrics and Neonatology, Osaka General Medical Center
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | | | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | - Yuichiro Maekawa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine
| | - Shigeru Makita
- Department of Cardiac Rehabilitation, Saitama International Medical Center, Saitama Medical University
| | - Yoshiro Matsui
- Department of Cardiac Surgery, Hanaoka Seishu Memorial Hospital
| | | | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | | | | | | | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | | | - Satoshi Hida
- Department of Cardiovascular Medicine, Tokyo Medical University
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | | | | | - Makoto Kawai
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | - Toshiro Kitagawa
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University School of Medicine
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Yoji Nagata
- Division of Cardiology, Fukui CardioVascular Center
| | - Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama
| | - Hiroyuki Morita
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Hitoshi Takano
- Department of Cardiovascular Medicine, Nippon Medical School Hospital
| | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine
| | | | - Shinsuke Yuasa
- Department of Cardiology, Keio University School of Medicine
| | - Teppei Yamamoto
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
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Tunca Sahin G, Ozgur S, Kafali HC, Sevinc Sengul F, Haydin S, Guzeltas A, Ergul Y. Clinical characteristics of hypertrophic cardiomyopathy in children: An 8-year single center experience. Pediatr Int 2021; 63:37-45. [PMID: 32682351 DOI: 10.1111/ped.14393] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 05/14/2020] [Accepted: 06/17/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is the second most common pediatric cardiomyopathy. Although there is a large body of literature about HCM in adults, there is limited information on HCM in childhood. We evaluated various aspects of pediatric HCM patients treated at our center. METHODS We identified 152 pediatric patients with HCM between October 2011 and October 2019. Clinical history, invasive (ICD, pacemaker, electrophysiologic study, catheter ablation therapy) and non-invasive (ECG, holter moniterization, echocardiography, cardiac MR, genetic study, medicam treatment) data were collected and evaluated. RESULTS The mean ± standard deviation age of patients was 8.9 ± 5.7 years (1 month-18 years) and 67.8% were male. The most frequent clinical symptoms were murmur and palpitations. Three cases (2%) had aborted sudden death as the first manifestation of HCM. Of these patients, 120 (78.9%) had non-syndromic HCM and 32 (27.2%) had syndromic HCM. Asymmetric septal hypertrophy was common (48.3%) in the non-syndromic group, whereas concentric hypertrophy was common (56.2%) in syndromic group. Left ventricular outflow tract obstruction (LVOTO) occurred in 39 (25.6%) patients. Nine (5.9%) patients underwent electrophysiologic study and/or ablation and 16 patients underwent surgical intervention. Implantable cardioverter defibrillator (ICD) insertion was performed in 38 patients (26 transvenous, 12 epicardial). ICDs were inserted in three (7.9%) patients for secondary prevention; in the remaining patients (92.1%) the devices were placed for primary prevention. Mean SD follow-up time was 27.1 ± 22 months. Five (3.3%) patients died during the follow-up. No patient had heart transplantation or a long-term assistive device. CONCLUSION The etiology of HCM is heterogeneous and present at any age. It is important to determine the timing of surgery and potential risks for sudden cardiac arrest. As most cases of HCM are familial, evaluation of family members at risk should be a routine component of clinical management.
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Affiliation(s)
- Gulhan Tunca Sahin
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Senem Ozgur
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Hasan Candas Kafali
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Fatma Sevinc Sengul
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Sertac Haydin
- Department of Pediatric Cardiovascular Surgery, Istanbul Saglik Bilimleri University, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Alper Guzeltas
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Yakup Ergul
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
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Sandrikov VА, Kulagina TY, Van EY, Gavrilov AV. [Echocardiography in the Assessment of Intraventricular Flows and Pressure Gradients in Obstructive Hypertrophic Cardiomyopathy]. ACTA ACUST UNITED AC 2020; 60:1245. [PMID: 33487152 DOI: 10.18087/cardio.2020.11.n1245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/23/2020] [Indexed: 11/18/2022]
Abstract
Aim To evaluate results of myomectomy by intraventricular pressure gradients (IVPG) and blood flows in patients with obstructive hypertrophic cardiomyopathy (OHCMP).Material and methods The study included a total of 76 subjects, 42 patients with OHCMP (mean age, 39±7 years) and 34 healthy volunteers (mean age, 41±3 years). Prior to and after myomectomy, transthoracic echocardiography was performed and followed by digital image processing and calculation of IVPG and left ventricular (LV) vortex flows. Vector analysis was used to estimate the myocardial displacement rate (V), vortex flows, and LV apex-to-base pressure gradients.Results The study showed a dynamic decrease in the LV apex-to-outflow IVPG by more than 50% and recovery of myocardial contraction velocity in the septal area (р<0.001). The decrease in LV cavity pressure gradient serves as an index for evaluating the effectiveness of OHCMP correction. Myomectomy reduces the load on the myocardium and abolishes mitral valve regurgitation with improvement of LV blood flows as also evidenced by the dynamics of long axis velocity change during the cardiac cycle (dL / dt) and the myocardial contraction velocity (V).Conclusion Effectiveness of the surgical correction of OHCMP is based on the dynamics of myocardial contraction velocities, vortex blood flows, and a decrease in LV apex-to-base IVPG.
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Affiliation(s)
- V А Sandrikov
- Scientific Institution "Petrovsky national research centre of surgery", Moscow
| | - T Yu Kulagina
- Scientific Institution "Petrovsky national research centre of surgery", Moscow
| | - E Yu Van
- Scientific Institution "Petrovsky national research centre of surgery", Moscow
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Moreno Garijo J, Amador Y, Fan CS, Silverton N, Ralph-Edwards A, Woo A, Mashari A, Meineri M. Association Between Three-Dimensional Left Ventricular Outflow Tract Area and Gradients After Myectomy in Hypertrophic Obstructive Cardiomyopathy. J Cardiothorac Vasc Anesth 2020; 35:1654-1662. [PMID: 33431273 DOI: 10.1053/j.jvca.2020.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Determine whether the intraoperative three-dimensional left ventricular outflow tract cross-sectional area may be inversely correlated with pressure gradients as a determinant of surgical success after septal myectomy in hypertrophic cardiomyopathy patients. DESIGN Perioperative data were obtained by retrospective review. SETTING Toronto General Hospital, University of Toronto, Toronto, Canada, a tertiary hospital. PARTICIPANTS The study comprised 67 patients with hypertrophic obstructive cardiomyopathy. INTERVENTIONS Transthoracic and intraoperative transesophageal echocardiographic assessment of pressure gradients. Transesophageal measurement of the three-dimensional left ventricular outflow tract cross-sectional area. MEASUREMENTS AND MAIN RESULTS The smallest left ventricular outflow tract area increased on average 1.883 cm2 (98.3%) after septal myectomy. There was a significant correlation between the increase in the area and the transesophageal pressure gradients (r = -0.32; p = 0.01) after myectomy, but none with postoperative transthoracic gradients at rest (r = -0.10; p = 0.42). Postoperative transesophageal and transthoracic gradients were significantly correlated (r = 0.26; p = 0.04). The best risk factors to predict high residual gradients were preoperative transesophageal gradient >97 mmHg, postoperative transesophageal area <3.16 cm2, and moderate or more residual transesophageal mitral regurgitation (specificity 89%, 81%, and 78%, respectively). CONCLUSIONS Three-dimensional left ventricular outflow tract area measurements with transesophageal echocardiography after myectomy correlated fairly well with postoperative transesophageal pressure gradients. Patients with residual transthoracic elevated gradients after surgery at follow-up had a smaller transesophageal area and higher transesophageal pressure gradients immediately after the procedure. However, transesophageal pressure gradients after myectomy correlated poorly with follow-up transthoracic gradients at rest.
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Affiliation(s)
- J Moreno Garijo
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada.
| | - Y Amador
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - C S Fan
- Department of Biostatistics, Toronto General Hospital, Toronto, ON, Canada
| | - N Silverton
- Department of Anesthesiology, University of Utah Health, Salt Lake City, UT
| | - A Ralph-Edwards
- Department of Cardiac Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - A Woo
- Department of Cardiology, Toronto General Hospital, Toronto, ON, Canada
| | - A Mashari
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - M Meineri
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
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11
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Javidgonbadi D, Abdon NJ, Andersson B, Schaufelberger M, Östman-Smith I. Short atrioventricular delay pacing therapy in young and old patients with hypertrophic obstructive cardiomyopathy: good long-term results and a low need for reinterventions. Europace 2019; 20:1683-1691. [PMID: 29121221 PMCID: PMC6182309 DOI: 10.1093/europace/eux331] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 10/23/2017] [Indexed: 12/12/2022] Open
Abstract
Aims Examination of long-term results following different treatments in hypertrophic obstructive cardiomyopathy (HOCM) in a complete geographical cohort. Methods and results HOCM patients attending during 2002–13 in all 10 hospitals in the West Götaland Region, Sweden, were identified (n = 251), follow-up 14.4 (±8.9) years (mean ± SD), 121 managed medically, 42 treated with myectomy and 88 with short atrioventricular (AV) delay pacing as first interventional procedure. Post-intervention follow-up was 12.9 ± 8.7 years and 12.2 ± 5.0 years, respectively. Both intervention treatments improved New York Heart Association (NYHA) class and outflow gradients significantly. Patients treated with pacing were older (median age 64 vs. 43 years, P < 0.001). Freedom from disease-related death post-procedure at 5, 10, and 20 years were 93%, 80%, 56% vs. 93%, 93%, 57% in pacing and myectomy groups, respectively (log-rank P = 0.43). Survival after diagnosis was not different in patients just treated conservatively (P = 0.51 pacing/conservative; P = 0.39 myectomy/conservative). Reintervention for outflow gradients in patients ≥18 years at procedure occurred in 3.5% in pacing group and 15.6% in myectomy group (P = 0.007). Pacing therapy was equally effective in patients aged 13–64 years (n = 44), as in patients ≥65 years (n = 44): resting gradient pre-procedure and at last follow-up were median (IQR) 65 (71) and 12 (20) mmHg for <65 year-olds (P < 0.001), and 75 (64) and 14 (38) mmHg, respectively, for ≥65 year-olds (P < 0.001). New York Heart Association class improved significantly in both age ranges to 1.6 ± 0.6 and 1.8 ± 0.7, respectively (P < 0.001; P < 0.001). Conclusion Short AV delay pacing provided lasting satisfactory relief of symptoms and outflow obstruction in the majority of patients, with low risk of requiring reintervention. Our findings support the view that pacing therapy should be considered a valid option to treat patients with HOCM.
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Affiliation(s)
- Davood Javidgonbadi
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Blå stråket 5B, Gothenburg, Sweden
| | - Nils-Johan Abdon
- Formerly Department of Medicine, Uddevalla Hospital, Fjällvägen 9, Uddevalla, Sweden (retired)
| | - Bert Andersson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Blå stråket 5B, Gothenburg, Sweden
| | - Maria Schaufelberger
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Blå stråket 5B, Gothenburg, Sweden
| | - Ingegerd Östman-Smith
- Department of Pediatrics, Institute of Clinical Sciences, Queen Silvia Children's Hospital, Rondvägen 10, Gothenburg, Sweden
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13
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Collis R, Rahman M, Watkinson O, Guttmann O, O'Mahony C, Elliott P. Outcomes following the surgical management of left ventricular outflow tract obstruction; A systematic review and meta-analysis. Int J Cardiol 2018; 265:62-70. [DOI: 10.1016/j.ijcard.2018.01.130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 12/15/2017] [Accepted: 01/30/2018] [Indexed: 01/20/2023]
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van der Merwe J, Casselman F, Van Praet F. Endoscopic Port Access TM left ventricle outflow tract resection and atrioventricular valve surgery. J Vis Surg 2018; 4:100. [PMID: 29963389 DOI: 10.21037/jovs.2018.05.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/21/2018] [Indexed: 11/06/2022]
Abstract
The continuous evolution in robotic-, endoscopic- and trans-catheter cardiac interventions resulted in innovative techniques that simultaneously address left ventricular outflow tract obstruction (LVOTO) and concomitant atrioventricular valve (AVV) pathology in the context of hypertrophic obstructive cardiomyopathy (HOCM). We present our brief report of 13 consecutive HOCM patients with concomitant AVV disease, who underwent endoscopic left ventricular septal myomectomy (LVSM) and AVV surgery by Endoscopic Port AccessTM Surgery (EPAS) between March 1st 2010 and October 31st 2015. Our EPAS technique in the context of HOCM utilizes peripheral cardiopulmonary bypass, endo-aortic balloon occlusion and a 4-cm right antero-lateral thoracic working port. Access to the LVOTO is obtained by detaching the anterior mitral valve (MV) leaflet from the annulus. Controlled sharp LVSM is then performed from the aortic leaflet base to the papillary muscles. Subsequent routine AVV surgery is performed using long shafted instruments. There were no sternotomy conversions, LVSM complications or 30-day mortalities. The mean length of hospitalization was 17.7±18.1 days. Long-term clinical and echocardiographic analysis of 645.7 patient-months (n=13, 100.0% complete) identified two late mortalities, which were not procedure-, HOCM- or AVV-related. All patients (n=13, 100.0%), including the late mortalities, had significant improvement in their quality of life, a 100% long-term freedom from re-intervention and no residual peak instantaneous LVOTO gradients more than 15 mmHg. This brief report emphasises that simultaneous LVSM and concomitant AVV surgery by EPAS can safely be performed in experienced centres with favourable long-term outcomes.
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Affiliation(s)
- Johan van der Merwe
- Department of Cardiovascular and Thoracic Surgery, Onze Lieve Vrouw Clinic, Aalst, Belgium
| | - Filip Casselman
- Department of Cardiovascular and Thoracic Surgery, Onze Lieve Vrouw Clinic, Aalst, Belgium
| | - Frank Van Praet
- Department of Cardiovascular and Thoracic Surgery, Onze Lieve Vrouw Clinic, Aalst, Belgium
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15
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Hypertrophic Cardiomyopathy-Past, Present and Future. J Clin Med 2017; 6:jcm6120118. [PMID: 29231893 PMCID: PMC5742807 DOI: 10.3390/jcm6120118] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 11/21/2017] [Accepted: 12/05/2017] [Indexed: 12/15/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy with a prevalence of 1 in 500 in the general population. Since the first pathological case series at post mortem in 1957, we have come a long way in its understanding, diagnosis and management. Here, we will describe the history of our understanding of HCM including the initial disease findings, diagnostic methods and treatment options. We will review the current guidelines for the diagnosis and management of HCM, current gaps in the evidence base and discuss the new and promising developments in this field.
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Collis R, Watkinson O, O'Mahony C, Guttmann OP, Pantazis A, Tome-Esteban M, Tsang V, Chandrasekaran V, McGregor CGA, Elliott PM. Long-term outcomes for different surgical strategies to treat left ventricular outflow tract obstruction in hypertrophic cardiomyopathy. Eur J Heart Fail 2017; 20:398-405. [PMID: 29148156 DOI: 10.1002/ejhf.1038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 08/25/2017] [Accepted: 09/01/2017] [Indexed: 11/12/2022] Open
Abstract
AIMS Surgical intervention is used to treat dynamic left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy. This study assesses the effect of different surgical strategies on long-term mortality and morbidity. METHODS AND RESULTS In total, 347 patients underwent surgical intervention for LVOTO (1988-2015). Group A (n = 272) underwent septal myectomy; Group B (n = 33), septal myectomy and mitral valve (MV) repair; Group C (n = 22), myectomy and MV replacement; and Group D (n = 20), MV replacement alone. Median follow-up was 5.2 years (interquartile range 1.9-7.9). The mean resting LVOT gradient improved post-operatively from 71.9 ± 39.6 mmHg to 13.4 ± 18.5 mmHg (P < 0.05). Overall, 72.4% of patients improved by >1 New York Heart Association (NYHA) class; 58.9% of patients undergoing MV replacement alone did not improve their NYHA class. There were 5 perioperative deaths and 20 late deaths (>30 days). Survival rates at 1, 5 and 10 years respectively were 98.4, 96.9, 91.9% in Group A; 97.0, 92.4, 61.6% in Group B; 100.0, 100.0, 55.6% in Group C; and 94.7, 85.3, 85.3% in Group D (log-rank, P < 0.05). Long-term (>30 days) complications included atrial fibrillation (29.6%), transient ischaemic attack/stroke (2.4%) and heart failure hospitalisation (3.2%). There were 16 repeat surgical interventions at 3.0 years. CONCLUSION Septal myectomy is a safe procedure resulting in symptomatic improvement in the majority of patients. The annual incidence of non-fatal disease-related complications after surgical treatment of LVOTO is relatively high. Patients who underwent MV replacements had poorer outcomes with less symptomatic benefit in spite of a similar reduction in LVOT gradients.
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Affiliation(s)
- Richard Collis
- Institute of Cardiovascular Science, University College London, London, UK.,Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Oliver Watkinson
- Institute of Cardiovascular Science, University College London, London, UK.,Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | | | | | | | - Maria Tome-Esteban
- Cardiology Clinical Academic Group, St George's University Hospitals NHS Foundation Trust, Tooting, London, UK
| | - Victor Tsang
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | | | | | - Perry M Elliott
- Institute of Cardiovascular Science, University College London, London, UK.,Barts Heart Centre, St Bartholomew's Hospital, London, UK
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Delmo Walter EM, Javier MF, Hetzer R. Long-term outcome of simultaneous septal myectomy and anterior mitral leaflet retention plasty in hypertrophic obstructive cardiomyopathy: the Berlin experience. Ann Cardiothorac Surg 2017; 6:343-352. [PMID: 28944175 DOI: 10.21037/acs.2017.03.08] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Various surgical strategies designed to relieve left ventricular outflow tract obstruction (LVOTO) and correct mitral regurgitation (MR) in hypertrophic obstructive cardiomyopathy (HOCM) have evolved, yet reports on the long-term outcomes of each technique are scarce. We provide an update on over 20 years' experience at our institution in the standardized surgical treatment of HOCM. METHODS Between April 1986 and April 2014, 320 cases of endomyocardial resection and 305 septal myectomies were performed at our institution. Out of this sample, 57 patients (mean age 38±2.5 years, median 16.2, range 3 months-79.8 years) underwent surgery for HOCM involving septal myectomy and anterior leaflet retention plasty (ALRP), intended to obviate the systolic anterior motion (SAM) phenomenon. The preoperative mean LVOT pressure gradient was 98.98±26.2 (median 90, range 60-160) mmHg with moderate-severe MR. Standard transaortic septal myectomy was performed by resecting long blocks of septal myocardium, continued apically beyond the point of the mitral-septal contact. Through a left atriotomy, the segment of anterior mitral leaflet (AML) closest to the trigones was sutured to the corresponding posterior annulus on both sides. Cardiopulmonary bypass was resumed for repeat septal myectomy if the LVOT pressure gradient was greater than 20 mmHg. RESULTS Following surgical correction, the mean LVOT pressure gradient was significantly decreased to 12.3±2.7 (median 14, 18-25) mmHg (P<0.001). Septal thickness was reduced from a preoperative mean of 28.2±3.4 (median 30, 25-34) to 10.5±1.1 (12, 15-23) mm (P<0.001). During a mean follow-up of 17.5±1.3 years (median 12, range 1-23.2 years), MR was trivial in 87% and SAM was non-existent in all, outcomes that were maintained at the latest follow-up. Two patients underwent mitral valve (MV) replacement 1 and 5 years after ALRP for recurrent MR. Two patients eventually underwent heart transplantation for end-stage heart failure, 2 and 11 years later, respectively. Twenty-year freedom from repeat MV intervention and cumulative survival rate was 92.9% and 91.2%, respectively. CONCLUSIONS Long-term follow up of HOCM patients who underwent simultaneous septal myectomy and ALRP showed sustained absence of SAM, attenuation of MI, absence of residual LVOT obstruction and sustained improvement in hemodynamic and functional status.
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Hamaoka T, Omi W, Sekiguti Y, Takata S, Kaneko S, Inoue O, Takashima S, Murai H, Usui S, Kato T, Furusho H, Takamura M. Intestinal angina in a patient with hypertrophic obstructive cardiomyopathy: a case report. J Med Case Rep 2016; 10:271. [PMID: 27686381 PMCID: PMC5043615 DOI: 10.1186/s13256-016-1055-8] [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: 06/17/2016] [Accepted: 09/05/2016] [Indexed: 11/25/2022] Open
Abstract
Background Intestinal angina is characterized by recurrent postprandial abdominal pain and anorexia. Commonly, these symptoms are caused by severe stenosis of at least two vessels among the celiac and mesenteric arteries. However, intestinal perfusion is affected not only by the degree of arterial stenosis but also by systemic perfusion. We experienced a unique case of intestinal angina caused by relatively mild stenosis of the abdominal arteries complicated with hypertrophic obstructive cardiomyopathy. Case presentation We report an 86-year old Japanese man with hypertrophic obstructive cardiomyopathy and advanced atrioventricular block who was diagnosed with intestinal angina. Computed tomography showed mild stenosis of the celiac artery and severe stenosis of the inferior mesenteric artery, and these lesions were relatively mild compared with other reports. A dual-chamber pacemaker with right ventricular apical pacing was implanted to improve the obstruction of the left ventricular outflow tract. After implantation, the patient’s abdominal symptoms diminished markedly, and improvement of the left ventricular outflow tract obstruction was observed. Conclusions Although intestinal angina is generally defined by severe stenosis of at least two vessels among the celiac and mesenteric arteries, the present case suggests that hemodynamic changes can greatly affect intestinal perfusion and induce intestinal angina in the presence of mild stenosis of the celiac and mesenteric arteries.
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Liebregts M, Vriesendorp PA, Mahmoodi BK, Schinkel AF, Michels M, ten Berg JM. A Systematic Review and Meta-Analysis of Long-Term Outcomes After Septal Reduction Therapy in Patients With Hypertrophic Cardiomyopathy. JACC-HEART FAILURE 2015; 3:896-905. [DOI: 10.1016/j.jchf.2015.06.011] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 06/09/2015] [Accepted: 06/12/2015] [Indexed: 11/15/2022]
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Patel P, Dhillon A, Popovic ZB, Smedira NG, Rizzo J, Thamilarasan M, Agler D, Lytle BW, Lever HM, Desai MY. Left Ventricular Outflow Tract Obstruction in Hypertrophic Cardiomyopathy Patients Without Severe Septal Hypertrophy. Circ Cardiovasc Imaging 2015; 8:e003132. [DOI: 10.1161/circimaging.115.003132] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
In patients with hypertrophic cardiomyopathy and left ventricular outflow tract (LVOT) obstruction, but without basal septal hypertrophy, we sought to identify mitral valve (MV) and papillary muscle (PM) abnormalities that predisposed to LVOT obstruction, using echo and cardiac magnetic resonance.
Methods and Results—
We studied 121 patients with hypertrophic cardiomyopathy hypertrophic cardiomyopathy (age, 49±17 years; 60% men; 57% on β-blockers) with a basal septal thickness of ≤1.8 cm who underwent echocardiography (rest+stress) and cine cardiac magnetic resonance. Echo measurements included maximal LVOT gradient (rest/provocable), MV leaflet length (parasternal long, 4 and 3-chamber views), and abnormal chordal attachment to mid/base of anterior MV. Cine cardiac magnetic resonance measurements included basal septal thickness, number/area of PM heads, and bifid PM mobility (in systole and diastole). Mean basal septal thickness, LVOT gradient, and LV ejection fraction were 1.5±0.3 cm, 72±54 mm Hg, and 61±6%, respectively. The number of anterolateral and posteromedial PM heads was 2.7±0.7 and 2.6±0.7, respectively. Anterolateral and posteromedial PM areas were 19.9±7 cm
2
and 17.1±6 cm
2
, respectively. PM mobility was 11±6°. On multivariable analysis, predictors of maximal LVOT gradient were basal septal thickness, bifid PM mobility, anterior mitral leaflet length, and abnormal chordal attachment to base of anterior mitral leaflet. Forty-five patients underwent surgery to relieve LVOT obstruction, of which 52% needed an additional nonmyectomy (MV repair/replacement or PM reorientation) approach.
Conclusions—
In hypertrophic cardiomyopathy patients without significant LV hypertrophy, in addition to basal septal thickness, anterior MV length, abnormal chordal attachment, and bifid PM mobility are associated with LVOT obstruction. In such patients, additional procedures on MV and PM (±myectomy) could be considered.
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Affiliation(s)
- Parag Patel
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Ashwat Dhillon
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Zoran B. Popovic
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Nicholas G. Smedira
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Jessica Rizzo
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Maran Thamilarasan
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Deborah Agler
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Bruce W. Lytle
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Harry M. Lever
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Milind Y. Desai
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
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Sedehi D, Finocchiaro G, Tibayan Y, Chi J, Pavlovic A, Kim YM, Tibayan FA, Reitz BA, Robbins RC, Woo J, Ha R, Lee DP, Ashley EA. Long-term outcomes of septal reduction for obstructive hypertrophic cardiomyopathy. J Cardiol 2015; 66:57-62. [DOI: 10.1016/j.jjcc.2014.08.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 07/16/2014] [Accepted: 08/14/2014] [Indexed: 11/15/2022]
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Wu JJ, Seco M, Medi C, Semsarian C, Richmond DR, Dearani JA, Schaff HV, Byrom MJ, Bannon PG. Surgery for hypertrophic cardiomyopathy. Biophys Rev 2015; 7:117-125. [PMID: 28509978 PMCID: PMC5418425 DOI: 10.1007/s12551-014-0153-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 11/25/2014] [Indexed: 01/17/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a genetically determined cardiac disease characterised by otherwise unexplained myocardial hypertrophy of the left ventricle, and may result in left ventricular outflow tract obstruction. It is the most common cause of sudden cardiac death in young adults due to arrhythmias. Septal myectomy is a surgical treatment for HCM with moderate to severe outflow tract obstruction, and is indicated for patients with severe symptoms refractory to medical therapy. The surgical approach involves obtaining access to the interventricular septum via transaortic, transapical or transmitral approaches, and excising a portion of the hypertrophied myocardium to relieve the outflow tract obstruction. Large, contemporary series from centres experienced in septal myectomy patients have demonstrated a low early mortality of <2 %, excellent long-term survival that matches the general population, and durable relief of symptoms.
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Affiliation(s)
- James J Wu
- Sydney Medical School, The University of Sydney, Sydney, Australia
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia
- Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael Seco
- Sydney Medical School, The University of Sydney, Sydney, Australia
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia
- Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Caroline Medi
- Molecular Cardiology Group, Centenary Institute, Sydney, NSW, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Chris Semsarian
- Sydney Medical School, The University of Sydney, Sydney, Australia
- Molecular Cardiology Group, Centenary Institute, Sydney, NSW, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - David R Richmond
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | | | - Michael J Byrom
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia
- Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul G Bannon
- Sydney Medical School, The University of Sydney, Sydney, Australia.
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia.
- Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia.
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Hensley N, Dietrich J, Nyhan D, Mitter N, Yee MS, Brady M. Hypertrophic Cardiomyopathy. Anesth Analg 2015; 120:554-569. [DOI: 10.1213/ane.0000000000000538] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, Hagege AA, Lafont A, Limongelli G, Mahrholdt H, McKenna WJ, Mogensen J, Nihoyannopoulos P, Nistri S, Pieper PG, Pieske B, Rapezzi C, Rutten FH, Tillmanns C, Watkins H. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J 2014; 35:2733-79. [PMID: 25173338 DOI: 10.1093/eurheartj/ehu284] [Citation(s) in RCA: 2845] [Impact Index Per Article: 284.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
MESH Headings
- Ablation Techniques/methods
- Adult
- Angina Pectoris/etiology
- Arrhythmias, Cardiac/etiology
- Cardiac Imaging Techniques/methods
- Cardiac Pacing, Artificial/methods
- Cardiomyopathy, Hypertrophic/diagnosis
- Cardiomyopathy, Hypertrophic/etiology
- Cardiomyopathy, Hypertrophic/therapy
- Child
- Clinical Laboratory Techniques/methods
- Death, Sudden, Cardiac/prevention & control
- Delivery of Health Care
- Diagnosis, Differential
- Electrocardiography/methods
- Female
- Genetic Counseling/methods
- Genetic Testing/methods
- Heart Failure/etiology
- Heart Valve Diseases/diagnosis
- Heart Valve Diseases/therapy
- Humans
- Medical History Taking/methods
- Pedigree
- Physical Examination/methods
- Preconception Care/methods
- Pregnancy
- Pregnancy Complications, Cardiovascular/diagnosis
- Pregnancy Complications, Cardiovascular/therapy
- Prenatal Care/methods
- Risk Factors
- Sports Medicine
- Syncope/etiology
- Thoracic Surgical Procedures/methods
- Ventricular Outflow Obstruction/etiology
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Faber L. Percutaneous Septal Ablation in Hypertrophic Obstructive Cardiomyopathy: From Experiment to Standard of Care. Adv Med 2014; 2014:464851. [PMID: 26556411 PMCID: PMC4590958 DOI: 10.1155/2014/464851] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 03/07/2014] [Indexed: 12/13/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is one of the more common hereditary cardiac conditions. According to presence or absence of outflow obstruction at rest or with provocation, a more common (about 60-70%) obstructive type of the disease (HOCM) has to be distinguished from the less common (30-40%) nonobstructive phenotype (HNCM). Symptoms include exercise limitation due to dyspnea, angina pectoris, palpitations, or dizziness; occasionally syncope or sudden cardiac death occurs. Correct diagnosis and risk stratification with respect to prophylactic ICD implantation are essential in HCM patient management. Drug therapy in symptomatic patients can be characterized as treatment of heart failure with preserved ejection fraction (HFpEF) in HNCM, while symptoms and the obstructive gradient in HOCM can be addressed with beta-blockers, disopyramide, or verapamil. After a short overview on etiology, natural history, and diagnostics in hypertrophic cardiomyopathy, this paper reviews the current treatment options for HOCM with a special focus on percutaneous septal ablation. Literature data and the own series of about 600 cases are discussed, suggesting a largely comparable outcome with respect to procedural mortality, clinical efficacy, and long-term outcome.
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Affiliation(s)
- Lothar Faber
- Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, University Hospital of the Ruhr University Bochum, Georgstraße 11, 32545 Bad Oeynhausen, Germany
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Bartels K, Daneshmand MA, Mathew JP, Glower DD, Swaminathan M, Nicoara A. Delayed postmyectomy ventricular septal defect. J Cardiothorac Vasc Anesth 2013; 27:381-4. [PMID: 23507017 DOI: 10.1053/j.jvca.2012.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Karsten Bartels
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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Samardhi H, Walters DL, Raffel C, Rateesh S, Harley C, Burstow D, Pohlner P, Aroney C. The long-term outcomes of transcoronary ablation of septal hypertrophy compared to surgical myectomy in patients with symptomatic hypertrophic obstructive cardiomyopathy. Catheter Cardiovasc Interv 2013; 83:270-7. [DOI: 10.1002/ccd.25134] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 05/30/2013] [Accepted: 07/11/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Himabindu Samardhi
- The Prince Charles Hospital; Rode Road, Chermside Brisbane Queensland 4032 Australia
- University of Queensland; Australia
| | - Darren L Walters
- The Prince Charles Hospital; Rode Road, Chermside Brisbane Queensland 4032 Australia
- University of Queensland; Australia
| | - Christopher Raffel
- The Prince Charles Hospital; Rode Road, Chermside Brisbane Queensland 4032 Australia
- University of Queensland; Australia
| | - Shruti Rateesh
- The Prince Charles Hospital; Rode Road, Chermside Brisbane Queensland 4032 Australia
- University of Queensland; Australia
| | - Catherine Harley
- The Prince Charles Hospital; Rode Road, Chermside Brisbane Queensland 4032 Australia
- University of Queensland; Australia
| | - Darryl Burstow
- The Prince Charles Hospital; Rode Road, Chermside Brisbane Queensland 4032 Australia
- University of Queensland; Australia
| | - Peter Pohlner
- The Prince Charles Hospital; Rode Road, Chermside Brisbane Queensland 4032 Australia
- University of Queensland; Australia
| | - Con Aroney
- The Holy Spirit Northside Hospital; 627 Rode Road, Chermside Brisbane Queensland 4032 Australia
- University of Queensland; Australia
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Desai MY, Bhonsale A, Smedira NG, Naji P, Thamilarasan M, Lytle BW, Lever HM. Predictors of Long-Term Outcomes in Symptomatic Hypertrophic Obstructive Cardiomyopathy Patients Undergoing Surgical Relief of Left Ventricular Outflow Tract Obstruction. Circulation 2013; 128:209-16. [DOI: 10.1161/circulationaha.112.000849] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
We report the predictors of long-term outcomes of symptomatic hypertrophic cardiomyopathy patients undergoing surgical relief of left ventricular outflow tract obstruction.
Methods and Results—
We studied 699 consecutive patients who have hypertrophic cardiomyopathy with severe symptomatic left ventricular outflow tract obstruction (47±11 years, 63% male) intractable to maximal medical therapy, who were referred to a tertiary hospital between January 1997 and December 2007 for the surgical relief of left ventricular outflow tract obstruction. We excluded patients <18 years of age, those with an ejection fraction <50%, those with hypertensive heart disease of the elderly, and those with more than mild aortic or mitral stenosis. Clinical, echocardiographic, and Holter data were recorded. A composite end point of death, appropriate internal cardioverter defibrillator discharges, resuscitated from sudden death, documented stroke, and admission for congestive heart failure was recorded. During a mean follow-up of 6.2±3 years, 86 patients (12%) met the composite end point with 30-day, 1-year, and 2-year event rates of 0.7%, 2.8%, and 4.7%, respectively. The hard event rate (death, defibrillator discharge, and resuscitated from sudden death) at 30 days, 1 year, and 2 years was 0%, 1.5%, and 3%, respectively. Stepwise multivariable analysis identified residual postoperative atrial fibrillation (hazard ratio, 2.12; confidence interval, 1.37–3.34;
P
=0.001) and increasing age (hazard ratio, 1.49; confidence interval, 1.22–1.82;
P
=0.001) as independent predictors of long-term composite outcomes.
Conclusions—
Symptomatic adult hypertrophic cardiomyopathy patients undergoing surgery for the relief of left ventricular outflow tract obstruction have low event rates during long-term follow-up; worse outcomes are predicted by increasing age and the presence of residual atrial fibrillation during follow-up.
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Affiliation(s)
- Milind Y. Desai
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Aditya Bhonsale
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | | | - Peyman Naji
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | | | - Bruce W. Lytle
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Harry M. Lever
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
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Lucon A, Palud L, Pavin D, Donal E, Behar N, Leclercq C, Mabo P, Daubert JC. Very late effects of dual chamber pacing therapy for obstructive hypertrophic cardiomyopathy. Arch Cardiovasc Dis 2013; 106:373-81. [DOI: 10.1016/j.acvd.2013.04.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 02/28/2013] [Accepted: 04/16/2013] [Indexed: 11/16/2022]
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Jacoby DL, DePasquale EC, McKenna WJ. Hypertrophic cardiomyopathy: diagnosis, risk stratification and treatment. CMAJ 2012; 185:127-34. [PMID: 23109605 DOI: 10.1503/cmaj.120138] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Daniel L Jacoby
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA.
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Yue-Cheng H, Zuo-Cheng L, Xi-Ming L, Yuan DZ, Dong-Xia J, Ying-Yi Z, Hui-Ming Y, Hong-Liang C. Long-term follow-up impact of dual-chamber pacing on patients with hypertrophic obstructive cardiomyopathy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 36:86-93. [PMID: 23078085 DOI: 10.1111/pace.12016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Revised: 07/18/2012] [Accepted: 08/14/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pacing has been proposed as a treatment for patients with hypertrophic obstructive cardiomyopathy (HOCM), but there are few studies with long-term follow-up. We evaluated the long-term effects of dual-chamber pacing therapy for patients with HOCM, and to identify the most prognosis-specific factors for predicting outcome in such treating methods. METHODS A total of 37 HOCM patients implanted with dual-chamber pacemakers were enrolled consecutively and followed-up. Thirty-seven cases were followed for 1 year, 26 cases for 2 years, 10 cases for 3 years, and eight cases for 4 years. At each annual point of follow-up after pacemaker implantation, the pacing frequency, pacing threshold, impedance, atrioventricular delay, and cumulative percentage of atrial and ventricular pacing were tested, respectively. In addition, left atrial dimension (LAD), left ventricular end diastolic dimension (LVEDd), left ventricular posterior wall thickness (LVPW), interventricular septum thickness (IVS), left ventricular outflow tract dimension (LVOTd), peak velocity of left ventricular outflow tract (VLVOT), left ventricular outflow tract pressure gradient (LVOTPG), left ventricular ejection fraction (LVEF), and pulmonary artery systolic pressure (PASP) were measured. Mitral valve systolic anterior motion (SAM) was also observed. Pacing parameters and echocardiography indexes before and after pacemaker implantation were dynamically compared. RESULTS Pacing frequency and atrioventricular delay were adjusted to 60-70 beats per minute and 90-180 ms, respectively, in order to ensure the ratio of ventricular pacing was more than 98%. Pacing threshold and pacing impedance were kept in normal ranges. The differences of various pacing parameters were of no statistical significance within the 4 years of follow-up (P > 0.05). Compared with prior to pacing, it was observed that the IVS, VLVOT, and LVOTPG declined significantly (P < 0.01), the LVOTd widened significantly (P < 0.01), and the SAM phenomenon improved obviously (P < 0.01) at 1, 2, 3, and 4 years after pacemaker implantation. Additionally, the changes in LAD, LVEDd, LVPW, LVEF, and PASP were statistically insignificant (P > 0.05). CONCLUSIONS The cardiac structural reconstruction in patients with HOCM can be chronically improved by dual-chamber pacing therapy. The IVS, LVOTd, VLVOT, and LVOTPG can be used as sensitive and specific factors in evaluating the long-term effects of dual-chamber pacing therapy for HOCM.
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Affiliation(s)
- Hu Yue-Cheng
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
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34
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Sorajja P, Binder J, Nishimura RA, Holmes DR, Rihal CS, Gersh BJ, Bresnahan JF, Ommen SR. Predictors of an optimal clinical outcome with alcohol septal ablation for obstructive hypertrophic cardiomyopathy. Catheter Cardiovasc Interv 2012; 81:E58-67. [PMID: 22511295 DOI: 10.1002/ccd.24328] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 01/03/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Alcohol septal ablation has emerged as a therapy for patients with obstructive hypertrophic cardiomyopathy (HCM). However, there are limited data on the predictors of success with the procedure. METHODS We examined patient characteristics and cardiac morphology as well as procedural data on 166 HCM patients (mean age, 63 years; 43% men), who underwent ablation at Mayo Clinic. Patients were contacted to determine vital status and symptoms to assess the primary endpoint of survival free of death and severe symptoms (New York Heart Association, class III or IV dyspnea). RESULTS The strongest patient characteristics that predicted clinical success were older age, less severe left ventricular outflow tract gradient, lesser ventricular septal hypertrophy, and a smaller left anterior descending (LAD) diameter. Mitral valve geometry or ventricular septal morphology did not predict outcome. Patients with ≥3 characteristics (age ≥65 years, gradient <100 mmHg, septal hypertrophy ≤18 mm, LAD diameter <4.0 mm) had superior 4-year survival free of death and severe symptoms (90.4%) in comparison to those with two characteristics (81.6%) and ≤1 characteristic (57.5%). Case volume with >50 patients was an independent predictor of survival free of severe symptoms. The volume of alcohol injected, number of arteries injected, or size of septal perforator artery were not predictive of clinical success. CONCLUSIONS Greater case volume and selection for key patient and anatomic characteristics are associated with superior outcomes with alcohol septal ablation.
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Affiliation(s)
- Paul Sorajja
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
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Recommendations for processing cardiovascular surgical pathology specimens: a consensus statement from the Standards and Definitions Committee of the Society for Cardiovascular Pathology and the Association for European Cardiovascular Pathology. Cardiovasc Pathol 2012; 21:2-16. [DOI: 10.1016/j.carpath.2011.01.001] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Accepted: 01/07/2011] [Indexed: 01/12/2023] Open
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36
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW. 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy. Circulation 2011; 124:e783-831. [PMID: 22068434 DOI: 10.1161/cir.0b013e318223e2bd] [Citation(s) in RCA: 505] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Bernard J. Gersh
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- ACCF/AHA Representative
| | - Barry J. Maron
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- ACCF/AHA Representative
| | | | - Joseph A. Dearani
- Society of Thoracic Surgeons Representative
- American Association for Thoracic Surgery Representative
| | - Michael A. Fifer
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- ACCF/AHA Representative
| | - Mark S. Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- Heart Rhythm Society Representative
| | - Srihari S. Naidu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- Society for Cardiovascular Angiography and Interventions Representative
| | | | | | - Harry Rakowski
- ACCF/AHA Representative
- American Society of Echocardiography Representative
| | | | | | - James E. Udelson
- Heart Failure Society of America Representative
- American Society of Nuclear Cardiology Representative
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37
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW, Jacobs AK, Smith SC, Anderson JL, Albert NM, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Krumholz HM, Kushner FG, Nishimura RA, Ohman EM, Page RL, Stevenson WG, Tarkington LG, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg 2011; 142:e153-203. [DOI: 10.1016/j.jtcvs.2011.10.020] [Citation(s) in RCA: 223] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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38
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW, Jacobs AK, Smith SC, Anderson JL, Albert NM, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Krumholz HM, Kushner FG, Nishimura RA, Ohman EM, Page RL, Stevenson WG, Tarkington LG, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: Executive summary. J Thorac Cardiovasc Surg 2011; 142:1303-38. [DOI: 10.1016/j.jtcvs.2011.10.019] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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39
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:2761-96. [PMID: 22068435 DOI: 10.1161/cir.0b013e318223e230] [Citation(s) in RCA: 594] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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40
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011; 58:2703-38. [PMID: 22075468 DOI: 10.1016/j.jacc.2011.10.825] [Citation(s) in RCA: 196] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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41
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2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e212-60. [PMID: 22075469 DOI: 10.1016/j.jacc.2011.06.011] [Citation(s) in RCA: 823] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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42
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Nasseri BA, Stamm C, Siniawski H, Kukucka M, Komoda T, Delmo Walter EM, Hetzer R. Combined anterior mitral valve leaflet retention plasty and septal myectomy in patients with hypertrophic obstructive cardiomyopathy. Eur J Cardiothorac Surg 2011; 40:1515-20. [DOI: 10.1016/j.ejcts.2011.03.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 03/25/2011] [Accepted: 03/28/2011] [Indexed: 10/18/2022] Open
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Fifer MA, Sigwart U. Controversies in cardiovascular medicine. Hypertrophic obstructive cardiomyopathy: alcohol septal ablation. Eur Heart J 2011; 32:1059-64. [PMID: 21447511 DOI: 10.1093/eurheartj/ehr013] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Alcohol septal ablation (ASA) was introduced in 1994 as an alternative to septal myectomy for patients with hypertrophic obstructive cardiomyopathy and symptoms refractory to medical therapy. This procedure alleviates symptoms by producing a targeted, limited infarction of the upper interventricular septum, resulting in an increase in left ventricular outflow tract (LVOT) diameter, a decrease in LVOT gradient, and regression of the component of LV hypertrophy that is due to pressure overload. Clinical success, with improvement in symptoms and reduction in gradient, is achieved in the great majority of patients with either resting or provocable LVOT obstruction. The principal morbidity of the procedure is complete heart block, resulting in some patients in the requirement for a permanent pacemaker. The introduction of myocardial contrast echocardiography as a component of the ASA procedure has contributed to the induction of smaller myocardial infarctions with lower dosages of alcohol and, in turn, fewer complications. Non-randomized comparisons of septal ablation and septal myectomy have shown similar mortality rates and post-procedure New York Heart Association class for the two procedures.
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Affiliation(s)
- Michael A Fifer
- Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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44
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Rothman RD, Safiia MA, Lowry PA, Mela T, Abbara S, O'Callaghan C, Mark EJ, Vlahakes GJ, Fifer MA. Risk stratification for sudden cardiac death after septal myectomy. J Cardiol Cases 2011; 3:e65-e67. [PMID: 30532839 DOI: 10.1016/j.jccase.2010.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 11/17/2010] [Accepted: 12/10/2010] [Indexed: 10/18/2022] Open
Abstract
Background The importance of risk stratification for sudden cardiac death (SCD) after septal myectomy for hypertrophic obstructive cardiomyopathy (HOCM) has not been emphasized previously. Methods and results We report 2 patients with SCD or ventricular tachycardia (VT) after septal myectomy for HOCM in whom risk factors for SCD were identified following surgical myectomy. One received an implantable cardioverter-defibrillator (ICD), which subsequently provided appropriate discharges for VT. The other delayed ICD implantation and suffered SCD. Conclusion These cases emphasize the importance of risk stratification for SCD after septal myectomy for HOCM.
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Affiliation(s)
- Richard D Rothman
- Cardiology Division, Department of Medicine, Cardiac Surgical Division, Department of Surgery, and Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Muhamad A Safiia
- Cardiology Division, Department of Medicine, Cardiac Surgical Division, Department of Surgery, and Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Patricia A Lowry
- Cardiology Division, Department of Medicine, Cardiac Surgical Division, Department of Surgery, and Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Theofanie Mela
- Cardiology Division, Department of Medicine, Cardiac Surgical Division, Department of Surgery, and Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Suhny Abbara
- Cardiology Division, Department of Medicine, Cardiac Surgical Division, Department of Surgery, and Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Caitlin O'Callaghan
- Cardiology Division, Department of Medicine, Cardiac Surgical Division, Department of Surgery, and Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Eugene J Mark
- Cardiology Division, Department of Medicine, Cardiac Surgical Division, Department of Surgery, and Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Gus J Vlahakes
- Cardiology Division, Department of Medicine, Cardiac Surgical Division, Department of Surgery, and Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael A Fifer
- Cardiology Division, Department of Medicine, Cardiac Surgical Division, Department of Surgery, and Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Faber L, Prinz C, Welge D, Hering D, Butz T, Oldenburg O, Bogunovic N, Horstkotte D. Peak systolic longitudinal strain of the lateral left ventricular wall improves after septal ablation for symptomatic hypertrophic obstructive cardiomyopathy: a follow-up study using speckle tracking echocardiography. Int J Cardiovasc Imaging 2010; 27:325-33. [PMID: 20694748 DOI: 10.1007/s10554-010-9678-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 07/26/2010] [Indexed: 01/19/2023]
Abstract
Speckle tracking echocardiography (STE) or two-dimensional (2D) strain imaging is a novel ultrasound method to assess myocardial deformation. Peak systolic longitudinal strain (PSLS) of the basal septum (IVS) and the opposite lateral (LVFW) wall were measured in addition to standard echocardiography in 88 consecutive patients (pts) with obstructive hypertrophic cardiomyopathy (HOCM) who underwent a septal ablation procedure (PTSMA) and who were re-evaluated 12 ± 12 after months. At baseline, PSLS was substantially reduced both in basal regions. While PSLS remained unchanged in the basal IVS, i.e. the target region for PTSMA (baseline: -5.3 ± 4.1%; follow-up: -6.0 ± 4.3%; P=0.06), it improved in the opposite LVFW (from -9.4 ± 4.7 to -12.4 ± 4.8%; P<0.0001). Wall thickness decreased in both regions (Septum: from 20 ± 4 to 17 ± 4 mm; P<0.0001; LV free wall: from 13 ± 2 to 12 ± 2 mm; P=0.001). PSLS correlated significantly with wall thickness, both at baseline and at follow-up. NYHA functional class (from 2.9 ± 0.4 to 1.6 ± 0.6; P<0.0001) and objective exercise capacity (from 96 ± 42 to 114 ± 42 W; P=0.001) improved together with the reduction of outflow obstruction (LVOTO: from 62 ± 30 to 11 ± 19 mm Hg at rest, from 121 ± 26 to 43 ± 40 mm Hg with provocation; P<0.0001). During the 12 months of observation, no patient had a severe adverse event. Regional myocardial deformation can be assessed quantitatively by STE. Reduction of LV afterload by elimination of the outflow gradient following a successful PTSMA with low doses of alcohol results in improvement of systolic lateral longitudinal function.
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Affiliation(s)
- Lothar Faber
- Department of Cardiology, Heart and Diabetes Center North-Rhine Westphalia, Ruhr-University Bochum, Georgstr. 11, 32545 Bad Oeynhausen, Germany.
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46
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Leonardi RA, Kransdorf EP, Simel DL, Wang A. Meta-Analyses of Septal Reduction Therapies for Obstructive Hypertrophic Cardiomyopathy. Circ Cardiovasc Interv 2010; 3:97-104. [DOI: 10.1161/circinterventions.109.916676] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Septal reduction for obstructive hypertrophic cardiomyopathy may be performed by surgical myectomy or alcohol septal ablation (ASA). Unlike surgical myectomy, ASA creates an intramyocardial scar that may potentiate the risk of ventricular arrhythmias and sudden cardiac death (SCD).
Methods and Results—
Systematic reviews for ASA and surgical myectomy were performed. Study selection and data extraction were completed independently by 2 investigators. Comparative data analyses were completed using a random effects model and regression analysis. Kappa statistics for agreement on initial study inclusion were high for both ASA (0.78; 95% CI, 0.68 to 0.88) and surgical myectomy studies (0.95; 95% CI, 0.84 to 1.0). Nineteen ASA studies (2207 patients) and 8 surgical myectomy studies (1887 patients) were included. Median follow-up was shorter for ASA than for myectomy studies (51 versus 1266 patient-years;
P
<0.001). For ASA and surgical myectomy, unadjusted rates (events/patient-years) of all-cause mortality (0.021 versus 0.018, respectively;
P
=0.37) and SCD (0.004 versus 0.003, respectively;
P
=0.36) were similar. Patients treated with ASA were older (weighted mean, 55 versus 44 years;
P
<0.001) and had less septal hypertrophy (weighted mean, 21 versus 23 mm;
P
<0.001) compared with those treated with myectomy. After adjustment for available baseline characteristics, odds ratios for treatment effect on all-cause mortality and SCD were 0.28 (95% CI, 0.16 to 0.46) and 0.32 (95% CI, 0.11 to 0.97), respectively, favoring ASA.
Conclusions—
Rates of all-cause mortality and SCD after both ASA and surgical myectomy were similarly low. Adjusted for baseline characteristics, the odds ratios for treatment effect on all-cause mortality and SCD were lower in ASA cohorts compared with surgical myectomy cohorts.
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Affiliation(s)
- Robert A. Leonardi
- From the Medical University of South Carolina (R.A.L.), Charleston, SC; Duke University Medical Center (E.P.K., A.W.), Durham, NC; and Durham Veterans Affairs Medical Center and Duke University Medical Center (D.L.S.), Durham, NC
| | - Evan P. Kransdorf
- From the Medical University of South Carolina (R.A.L.), Charleston, SC; Duke University Medical Center (E.P.K., A.W.), Durham, NC; and Durham Veterans Affairs Medical Center and Duke University Medical Center (D.L.S.), Durham, NC
| | - David L. Simel
- From the Medical University of South Carolina (R.A.L.), Charleston, SC; Duke University Medical Center (E.P.K., A.W.), Durham, NC; and Durham Veterans Affairs Medical Center and Duke University Medical Center (D.L.S.), Durham, NC
| | - Andrew Wang
- From the Medical University of South Carolina (R.A.L.), Charleston, SC; Duke University Medical Center (E.P.K., A.W.), Durham, NC; and Durham Veterans Affairs Medical Center and Duke University Medical Center (D.L.S.), Durham, NC
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Shah A, Duncan K, Winson G, Chaudhry FA, Sherrid MV. Severe symptoms in mid and apical hypertrophic cardiomyopathy. Echocardiography 2010; 26:922-33. [PMID: 19968680 DOI: 10.1111/j.1540-8175.2009.00905.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We analyzed the clinical and quantitative echocardiographic characteristics of patients with sub-basal hypertrophic cardiomyopathy (HCM) to define the characteristics of patients (pts) with severe symptoms. METHODS Of 444 pts in a referral-based HCM program, 22 (5%) had midventricular or apical HCM. Quality of life (QoL) questionnaire was administered as an independent confirmer of symptomatic state. RESULTS Ten pts were NYHA III and IV, and 12 pts were NYHA I and II; QoL scores (41 +/- 26 vs. 10 +/- 13, P = 0.001) confirmed a priori division of two groups based on NYHA classification. Pts with more severe symptoms were more likely female (70% vs. 25%, P = 0.001) with atrial fibrillation (40% vs. 0%, P = 0.02). They more frequently had midventricular HCM 60% versus 8% (P = 0.01) (mid-LV thickness 17 +/- 6 vs. 12 +/- 2 mm, P = 0.03) and had much smaller LV diastolic volumes 68 +/- 12 versus 102 +/- 22 ml (39 +/- 4 vs. 53 +/- 12 ml/m(2), P = 0.001). Septal E/E' was higher in the severely symptomatic pts (15 +/- 5 vs. 7 +/- 3, P = 0.001) indicating higher estimated LV filling pressure. Midobstruction with apical akinetic chamber was noted in 4/10 pts who developed refractory symptoms. Cardiac mortality was higher in the severely symptomatic patients, 4/10 who had midventricular HCM as compared to 0/12 in the mildly symptomatic apical HCM group (P = 0.03). CONCLUSIONS In subbasal HCM, pts with severe symptoms have midventricular hypertrophy, with encroachment of the LV cavity and consequent very small LV volumes that may be complicated by mid-LV obstruction. Pts with mid-LV hypertrophy are more symptomatic than those with apical HCM, are often refractory to therapy, and have higher mortality.
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Affiliation(s)
- Ajay Shah
- Division of Cardiology, St. Luke's-Roosevelt Hospital Center, College of Physicians and Surgeons, Columbia University, New York City, New York, USA
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Sohns C, Sossalla S, Schmitto JD, Jacobshagen C, Raab BW, Obenauer S, Maier LS. Visualization of transcoronary ablation of septal hypertrophy in patients with hypertrophic obstructive cardiomyopathy: a comparison between cardiac MRI, invasive measurements and echocardiography. Clin Res Cardiol 2010; 99:359-68. [PMID: 20503122 PMCID: PMC2876266 DOI: 10.1007/s00392-010-0128-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Accepted: 01/22/2010] [Indexed: 01/19/2023]
Abstract
Objective Hypertrophic obstructive cardiomyopathy (HOCM) is treated by surgical myectomy or transcoronary ablation of septal hypertrophy (TASH). The aim of this study was to visualize the feasibility, success and short-term results of TASH on the basis of cardiac MRI (CMR) in comparison with cardiac catheterization and echocardiography. Methods In this in vivo study, nine patients with HOCM were treated with TASH. Patients were evaluated by transthoracic echocardiography, invasive cardiac angiography and CMR. Follow-up examinations were carried out after 1, 3 and 12 months. MR imaging was performed on a 1.5-T scanner. All images were processed using the semiautomatic Argus software and were evaluated by an attending thoracic radiologist and cardiologist. Results The echocardiographic pressure gradient (at rest) was 69.3 ± 15.3 mmHg before and 22.1 ± 5.7 mmHg after TASH (P < 0.01, n = 9). The flux acceleration over the aortic valve examined (Vmax) was 5.1 ± 0.6 m/s before and 3.4 ± 0.3 m/s after the TASH procedure (P < 0.05). Also, there was a decrease of septum thickness from 22.0 ± 1.2 to 20.2 ± 1.0 mm (P < 0.05) after 6 ± 3 weeks. The invasively assessed pressure gradient at rest was reduced from 63.7 ± 15.2 to 21.2 ± 11.1 mmHg (P < 0.01) and the post-extrasystolic gradient was reduced from 138.9 ± 12.7 to 45.6 ± 16.5 mmHg (P < 0.01). All differences as well as the quantity of injected ethanol were plotted against the size or amount of scar tissue as assessed in the MRI. There was a statistically significant correlation between the post-extrasystolic gradient decrease and the amount of scar tissue (P = 0.03, r2 = 0.5). In addition, the correlation between the quantity of ethanol and scar tissue area was highly significant (P < 0.01, r2 = 0.6), whereas the values for the gradient deviation (P = 0.10, r2 = 0.34), ΔVmax (P = 0.12, r2 = 0.31), as well as the gradient at rest (P = 0.27, r2 = 0.17) were not significant. Conclusion TASH was consistently effective in reducing the gradient in all patients with HOCM. In contrast to the variables investigated by echocardiography, the invasively measured post-extrasystolic gradient correlated much better with the amount of scar tissue as assessed by CMR. We conclude that the optimal modality to visualize the TASH effect seems to be a combination of CMR and the invasive identification of the post-extrasystolic gradient.
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Affiliation(s)
- Christian Sohns
- Department of Cardiology and Pneumology/Heart Center, Georg-August-University Goettingen, Robert-Koch-Str. 40, 37075 Goettingen, Germany
| | - Samuel Sossalla
- Department of Cardiology and Pneumology/Heart Center, Georg-August-University Goettingen, Robert-Koch-Str. 40, 37075 Goettingen, Germany
| | - Jan D. Schmitto
- Department of Cardiology and Pneumology/Heart Center, Georg-August-University Goettingen, Robert-Koch-Str. 40, 37075 Goettingen, Germany
- Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - Claudius Jacobshagen
- Department of Cardiology and Pneumology/Heart Center, Georg-August-University Goettingen, Robert-Koch-Str. 40, 37075 Goettingen, Germany
| | - Björn W. Raab
- Department of Cardiology and Pneumology/Heart Center, Georg-August-University Goettingen, Robert-Koch-Str. 40, 37075 Goettingen, Germany
- Department of Radiology, Georg-August-University Goettingen, Goettingen, Germany
| | - Silvia Obenauer
- Department of Cardiology and Pneumology/Heart Center, Georg-August-University Goettingen, Robert-Koch-Str. 40, 37075 Goettingen, Germany
- Department of Radiology, Georg-August-University Goettingen, Goettingen, Germany
| | - Lars S. Maier
- Department of Cardiology and Pneumology/Heart Center, Georg-August-University Goettingen, Robert-Koch-Str. 40, 37075 Goettingen, Germany
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Reflections of Inflections in Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2009; 54:212-9. [DOI: 10.1016/j.jacc.2009.03.052] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Accepted: 03/18/2009] [Indexed: 11/18/2022]
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Fernandes VL, Nielsen C, Nagueh SF, Herrin AE, Slifka C, Franklin J, Spencer WH. Follow-up of alcohol septal ablation for symptomatic hypertrophic obstructive cardiomyopathy the Baylor and Medical University of South Carolina experience 1996 to 2007. JACC Cardiovasc Interv 2009; 1:561-70. [PMID: 19463359 DOI: 10.1016/j.jcin.2008.07.005] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Revised: 07/21/2008] [Accepted: 07/23/2008] [Indexed: 01/19/2023]
Abstract
OBJECTIVES This study sought to determine the long-term outcome of alcohol septal ablation (ASA). BACKGROUND There are inadequate data on the long-term outcome of ASA for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). METHODS Six hundred and twenty-nine patients were enrolled consecutively (1996 to 2007) and 98.4% (n = 619) underwent ASA with 92% follow-up in 2007. Evaluation included deaths, procedural complications, pacemaker requirement, repeat ASA, and myectomy/valve surgery. Follow-up parameters included angina (Canadian Cardiovascular Society score), dyspnea (New York Heart Association functional class), exercise time, and echocardiographic indices (septal thickness, ejection fraction, resting and provoked gradients). RESULTS Ethanol (2.6 +/- 1.0 ml) was injected into 1.3 +/- 0.5 septal arteries, inducing a septal infarct. Complications included death 1% (n = 6), permanent pacemaker requirement 8.2% (n = 52), coronary dissection 1.3% (n = 8), and worsening mitral regurgitation 0.3% (n = 2). The mean follow-up was 4.6 +/- 2.5 years (range: 3 months to 10.2 years). During follow-up, New York Heart Association functional class decreased from 2.8 +/- 0.6 to 1.2 +/- 0.5 (p < 0.001); Canadian Cardiovascular Society angina score decreased from 2.1 +/- 0.9 to 1.0 +/- 0 (p < 0.001); and exercise time increased from 4.8 +/- 3.3 to 8.2 +/- 1.0 (p < 0.001) min. The resting and provoked left ventricular outflow tract gradients decreased progressively (p < 0.001) and remained low during follow-up. The septal thickness decreased from 2.1 +/- 0.5 cm to 1.0 +/- 0.1 cm (p < 0.001) and the ejection fraction decreased from 68 +/- 9% to 62 +/- 3% (p < 0.001). The survival estimates at 1, 5, and 8 years were 97%, 92%, and 89%, respectively. CONCLUSIONS The initial benefits of ASA were maintained during follow-up.
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