Alcohol Septal Abla-on: Is This Now First Line Treatment for Hypertrophic Obstruc-ve Cardiomyopathy (HOCM)?
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1 Alcohol Septal Abla-on: Is This Now First Line Treatment for Hypertrophic Obstruc-ve Cardiomyopathy (HOCM)? Sarang Mangalmur+, MD Bryn Mawr Hospital, PA NCVH New Jersey 2015
2 Disclosures No relevant disclosures for this presenta-on.
3 Hypertrophic Cardiomyopathy (HCM) LeQ Ventricular Hypertrophy Various Morphologies Asymmetric septal hypertrophy (ASH) Mid cavity hypertrophy/obstruc-on Apical hypertrophy Biventricular Complex obstruc-ve
4 Classic Septal Hypertrophy circahajournal courtesy
5 Systolic Anterior Mo-on Mitral Valve circahajournals.org
6 Pathophysiology LVOT Obstruc-on Res-ng/Dynamic gradient Diastolic Dysfunc-on Myocardial Ischemia Mitral Regurgita-on Degree propor-onal to LVOT obstruc-on
7 Clinical Presenta-on Conges-ve Heart Failure Dyspnea (80%), Orthopnea, PND Chest Pain (25-30%) Syncope/Presyncope (15-20%) Arrhythmia Sudden Cardiac Death (15%)
8 Treatment Approaches Pharmacologic Beta Blockers, Verapamil, Disopyramide Septal Myectomy Alcohol Septal Abla-on Dual Chamber Pacing (limited role)
9 Treatment algorithm for hypertrophic cardiomyopathy (HCM) patients with heart failure symptoms of exertional dyspnea with or without chest pain. Copyright American Heart Association, Inc. All rights reserved.
10 Surgical Myectomy Schematic Diagram of a Patient Undergoing Surgical Septal Myectomy Nishimura, R. A. et al. N Engl J Med 2004;350: Copyright 2004 Massachusetts Medical Society. All rights reserved.
11 Complica-ons of Myectomy Ventricular Septal Defect (2%) Need for PPM (surgery injures leq bundle) In Hospital Mortality (1-2% experienced centers)
12 Alcohol Septal Abla-on
13 Abla-on Technique
14 LVOT Gradient Reduc-on
15 Complica-ons Complete Heart Block (10%) Frequently injures the right bundle. (RBBB) Infarct Extension Ventricular Arrhythmias (2%) Vessel Injury (1%)
16 Anatomic Differences Barry J. Maron, and Rick A. Nishimura Circulation. 2014;130: Copyright American Heart Association, Inc. All rights reserved.
17 Anatomic Differences Variable Results with Alcohol Septal Abla-on 25% sparing of basal septum/gradient Surgery results in lower residual LVOT gradients Massive LV hypertrophy (thickness > 30 mm) septal abla-on limited
18 Age < 65 JACC 2005; Circ 2008 Copyright American Heart Association, Inc. All rights reserved.
19 Clinical Outcomes Comparable No randomized trials available Meta- analysis 2009 (Alam M, et al Eur Heart ) In- Hospital Mortality Improvements in NYHA Class Higher rates of PPM in Septal Abla-on Myocardial Contrast ECHO reduces CHB
20 Mul-center Data (N=1047) Survival Survival free from sudden cardiac death JACC: Heart Failure, Volume 2, Issue 6, 2014,
21 Survival free of all-cause mortality for patients with septal ablation (observed). Paul Sorajja et al. Circulation. 2012;126: Copyright American Heart Association, Inc. All rights reserved.
22 Survival free of all-cause mortality for patients with septal ablation in comparison with ageand sex-matched population of patients who underwent surgical myectomy. Paul Sorajja et al. Circulation. 2012;126: Copyright American Heart Association, Inc. All rights reserved.
23 JACC: Cardiovascular Interven-ons, Volume 7, Issue 11, 2014,
24 Septal Abla-on vs. Myectomy Alcohol Septal Abla-on Is Here To Stay Despite anatomic limita-ons similar rates of Survival and Reduc-on in Heart Failure Symptoms Non- randomized data
25 Advantages of Each Therapy Surgical Myectomy Higher and More Consistent LVOT reduc-on Lower incidence of PPM ( 3% vs 10%) Greater symptom relief in age < 65 years Treat concominant surgical problems (MR, etc) Alcohol Septal Abla-on Lower risk (elderly, comorbidi-es) Lower risk of VSD
26 2011 ACC/AHA Guidelines Septal myectomy is preferred treatment op-on for most severely symptoma-c HOCM pa-ents, especially young. Alcohol Septal Abla-on reserved for pa-ents high risk for surgical interven-on, par-cularly elderly.
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