The 2014 Mayo Approach to the Management of HCM and Non-Compaction
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1 The 2014 Mayo Approach to the Management of HCM and Non-Compaction R A Nishimura MD MACC MACP Judd and Mary Morris Leighton Professor Mayo Clinic No disclosures or conflict of interest CP
2 Let s start with a case 52 y/o man Class III DOE Loud murmur 300 mg lopressor Gradient 100 mmhg CP
3 Next step? 1. More meds 2. Dual chamber PM 3. Septal ablation 4. Septal myectomy 5. AICD CP
4 Treatment of HCM Relieve Symptoms Prevent Sudden Death Dynamic LVO Obstruction CP
5 Relieve obstruction Improve diastolic filling Reduce MR Improve symptoms Gradient LAP CP
6 Hypertrophic Cardiomyopathy Medical therapy : symptomatic pt Intolerant Beta Blockers Ca Blockers Intolerant Disopyramide Continued symptoms Myectomy DDD pacing Ablation CP
7 Dual Chamber Pacing NSR PACE CP CP
8 New medicines and other cures always work miracles for awhile William Heberden 1877 CP
9 Hypertrophic Cardiomyopathy Dual chamber pacing update 2014 Placebo effect wears out 6 months Overall improvement < 30% patients Possible detrimental effect Long-term pacing : myocardial dysfunction Mayo data CP
10 Septal Reduction Therapy CP
11 Septal Reduction Therapy Septal Myectomy CP
12 Surgical septal myectomy for symptomatic HOCM is safe and effective In the hands of experienced surgeons Operative mortality 0.8% Gradient 3 mm Post-op NYHA % CP
13 Septal Myectomy: Mayo Data pts F/U 10 yrs 80 % Pts I-II III-IV 20 0 Before Postop CP
14 Myectomy and Survival Nonobstructive Myectomy (Mayo) Overall survival Same results for cardiac survival and sudden death Nonoperated obstructive P< Ommen et al: JACC, 2005 Years CP CP
15 Hypertrophic Cardiomyopathy It is clear that surgical myectomy will result in marked long-lasting symptomatic improvement in over 90% of patients with severe symptoms and obstruction CP
16 Septal Ablation The New Kid on the Block A localized heart attack CP
17 Septal Ablation CP
18 Hypertrophic Cardiomyopathy 150 mm Hg 150 mm Hg 0 mm Hg Baseline 0 mm Hg After ablation CP CP
19 Surgery now has no role in the management of HCM Ablation is the new gold standard for the 21 st century Myectomy is only an impediment to the development of alcohol ablation Heart 2006:92:1339 JACC 2004:44:2054 Br J Card 2006:13:58 CP
20 Septal Ablation Success rate Structural Anatomy Anatomy Coronaries CP
21 No Systolic Anterior Motion of Mitral Valve Ablation ineffective Fixed subaortic stenosis 8-10% of referrals CP
22 MR jet directed anteriorly Ablation ineffective Flail leaflet 7-8% CP
23 Septal Ablation Success Structural Anatomy Anatomy Coronaries CP
24 Septal perfusion: just right CP
25 Septal perfusion: too much CP
26 Septal perfusion:?????? CP
27 Septal Ablation There are a subgroup of patients in whom the targeted septum cannot be reached by septal perforators CP
28 Septal myectomy Pre Post CP
29 Septal ablation Pre Post CP
30 Septal Ablation Complicatons Short Term Follow-up CP
31 Complete Heart Block (10-18%) CP
32 Ventricular Fibrillation Incidence unknown Sudden unexpected CP
33 Septal Ablation Other acute complications Coronary dissection: 0-2.5% (1.8%) Large infarction:???? Tamponade:.8-5% (3%) Stroke: 1.1% Nagueh JACC 2001 Faber EJE 2004 Fernandez JACC CV Int 2008 Firoozi EHJ 2002 Qin JACC 2001 Ralph-Edwards JTCVS 2005 Alam J int C 2006 Baggish Heart 2006 CP
34 This needs to be done in an experienced center!!!! 25 y/o Ablation done Now on transplant list CP
35 Septal Ablation Clinical Outcome CP
36 Survival without Severe Sx Pts aged <65 yrs Myectomy 90% Ablation p= % 20 0 No. at risk Myectomy Ablation Sorajja et al, Circ 2008 Follow-up (yrs) CP CP
37 Septal Ablation 4 yr survival free of death, NYHA Class III/IV or myectomy : 76% 1 of 4 will not have benefit CP
38 Ablation Myectomy Elderly Co-morbidities Limited life-span Sedentary Younger Healthy Long life-span Active CP
39 Patients/year 250 Septal Reduction Therapy Mayo Clinic Myectomy Ablation Year CP
40 Treatment of HCM Relieve Symptoms Prevent Sudden Death CP
41 Can we identify those patients at risk for sudden death? CP
42 Risk Factors for Sudden Death Really Bad Arrest Sustained VT Bad FH HCM and Sudden death LVH > 30 mm Unexplained syncope Somewhat Bad NSVT BP drop TMET Gadolinium DE LVO CAD CP
43 AICD: Caveats 72 y/o with four episodes syncope over 5 years 18 y/o with one episode syncope 1 week ago CP
44 Let s finish with a case LV RV 54 y/o woman Atypical chest pain Normal exam CP
45 What would you do? 1. Right and left heart cath / bx 2. Observation only 3. AICD 4. Anticoagulation 5. Surgery CP
46 Noncompaction of the myocardium A failure of the normal embryologic development of the heart Myocardium noncompacted (ratio 2:1 of trabeculated to solid) Early studies High rate of sudden death, stroke, etc CP
47 Noncompaction Wide spectrum of prognosis Benign Malignant Systolic function Symptoms Family history CP
48 Noncompaction Wide spectrum of prognosis Benign Malignant Observe Reassure AICD Anticoagulation CP
49 The 2014 Mayo Approach to the Management of HCM and Non-Compaction R A Nishimura MD MACC MACP Judd and Mary Morris Leighton Professor Mayo Clinic No disclosures or conflict of interest CP
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