Alcohol septal ablation for obstructive hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is an inhered heart disease characterised by a thickened heart muscle, common in 1:500 persons. Obstruction of blood flow in the heart due the thickened heart muscle can occur and cause dyspnoea. A heart surgeon can cut away part of the thickened muscle (myectomy). With alcohol septal ablation (ASA), an interventional cardiologist creates a small myocardial infarction by injecting alcohol in a side branch of the coronary arteries. Both techniques locally reduce the thick myocardium and alleviate obstruction and dyspnoea. In the current research mortality was found higher, when residual obstruction was present after ASA and when infarctions were larger. A higher dosage of alcohol was not more effective. A too distally chosen side branch for alcohol injection was ineffective for relief of the obstruction. With CMR research distal compared to basal myocardial infarction location, was less effective for relief of the obstruction. Young (43 years average) compared to older patients have good results after ASA and a lower complication rate. Both ASA and myectomy are effective for symptom improvement and have a good survival rate. Though complications are less common and in-hospital stay was shorter after ASA, second ASA procedure and pacemaker implantations were more common. In conclusion: both ASA and myectomy are safe and effective procedures for treatment of obstructive HCM. The interventional cardiologist should strive for a small and basal located myocardial infarction. ASA is less invasive in nature, but is offset by a higher chance for a pacemaker implantation and a second ASA procedure

Additive value of dobutamine stress echocardiography in patients with an anomalous origin of a coronary artery

An anomalous origin of a coronary artery (AOCA) is the second most common cause of non-traumatic sudden cardiac death in young athletes. Patients with a malignant course of an AOCA of the right coronary artery only need surgical correction when myocardial ischaemia is detected. An AOCA and its malignant or benign course can be detected by coronary angiography, coronary computed tomography or cardiac magnetic resonance imaging. Detection of ischaemia can be more difficult since even a negative maximal-effort stress ECG does not exclude a potential lethal coronary anomaly. Also, there are no case series or trials showing sensitivity or specificity for any form of ischaemia detection for AOCA in the literature. Although not described previously in adults, dobutamine stress echocardiography was previously described in a paediatric population with AOCA. We are the first to describe ischaemia detection by dobutamine stress echocardiography in three adult patients with an AOCA of the right coronary artery who were subsequently referred for surgery

Periprocedural Complications and Long-Term Outcome After Alcohol Septal Ablation Versus Surgical Myectomy in Hypertrophic Obstructive Cardiomyopathy A Single-Center Experience

AbstractObjectivesThis study compared alcohol septal ablation (ASA) and surgical myectomy for periprocedural complications and long-term clinical outcome in patients with symptomatic hypertrophic obstructive cardiomyopathy.BackgroundDebate remains whether ASA is equally effective and safe compared with myectomy.MethodsAll procedures performed between 1981 and 2010 were evaluated for periprocedural complications and long-term clinical outcome. The primary endpoint was all-cause mortality; secondary endpoints consisted of annual cardiac mortality, New York Heart Association functional class, rehospitalization for heart failure, reintervention, cerebrovascular accident, and myocardial infarction.ResultsA total of 161 patients after ASA and 102 patients after myectomy were compared during a maximal follow-up period of 11 years. The periprocedural (30-day) complication frequency after ASA was lower compared with myectomy (14% vs. 27%, p = 0.006), and median duration of in-hospital stay was shorter (5 days [interquartle range (IQR): 4 to 6 days] vs. 9 days [IQR: 6 to 12 days], p < 0.001). After ASA, provoked gradients were higher compared with myectomy (19 [IQR: 10 to 42] vs. 10 [IQR: 7 to 13], p < 0.001). After multivariate analysis, age (per 5 years) (hazard ratio: 1.34 [95% confidence interval: 1.08 to 1.65], p = 0.007) was the only independent predictor for all-cause mortality. Annual cardiac mortality after ASA and myectomy was comparable (0.7% vs. 1.4%, p = 0.15). During follow-up, no significant differences were found in symptomatic status, rehospitalization for heart failure, reintervention, cerebrovascular accident, or myocardial infarction between both groups.ConclusionsSurvival and clinical outcome were good and comparable after ASA and myectomy. More periprocedural complications and longer duration of hospital stay after myectomy were offset by higher gradients after ASA

Basal infarct location but not larger infarct size is associated with a successful outcome after alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy: a cardiovascular magnetic resonance imaging study

Alcohol septal ablation (ASA) is successful in most but not in all patients with obstructive hypertrophic cardiomyopathy (HCM). We therefore sought to investigate the relation between infarct location versus infarct size with outcome after ASA in patients with obstructive HCM. Baseline characteristics, procedural characteristics, and cardiovascular magnetic resonance findings at baseline and 4-6 month follow-up after ASA were analysed in 47 patients with obstructive HCM in a single-center retrospective study. Infarct size was determined using late gadolinium enhancement. Infarct location was divided into "basal infarction" and "distal infarction" based on an optimal cut-of value of the distance from the basal septum to the beginning of the infarction. A "successful" outcome was defined as 80 % reduction of the invasive gradient with a post-procedural gradient of <10 mmHg. Basal infarctions (n = 31) compared to distal infarctions (n = 16) were associated with successful outcome (100 vs. 38 %, P <0.001). Larger infarct size (n = 20) compared to smaller infarct size (n = 27) was not associated with successful outcome (75 vs. 82 %, P = 0.72). A more distal location of the infarction, was the only predictor of a less successful outcome (odds ratio 0.76, 95 % confidence interval 0.54-0.98, P = 0.03). Basal versus distal infarctions were also associated with a lower provoked gradient at late (2.6 +/- A 2.2 years) follow-up (11 (6-20) vs. 27 (12-94) mmHg, P = 0.01). Basal infarctions were associated with a successful outcome after ASA. A larger infarct size was not associated with a better outcome