Septal ablation in Hypertrophic Cardiomyopathy

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Septal ablation in Hypertrophic Cardiomyopathy
Charles Knight London Chest Hospital Advanced
Angioplasty 2003
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Terminology

• Non-surgical septal reduction (NSSR)
• Percutaneous transluminal septal myocardial
  ablation (PTSMA)
• Transcoronary ablation of septal hypertrophy
  (TASH)
• Septal ablation
• Alcohol ablation
• HOCM ablation
• Sigwart procedure

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• History
• 1980s
• Preliminary experiments
• by Ulrich Sigwart at Laussane
• Temporary balloon occlusion
• of first septal artery
• Injection of verapamil down
• first septal artery
• June 1994
• First septal ablation by Ulrich
• Sigwart at Royal Brompton
• 1997
• Described as profoundly aggressive with an
  unacceptably high mortality and morbidity in
  NEJM

NEJM 1997337349
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Myotomy-myectomy
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Patient selection

• No evidence for effect on prognosis
• Majority of patients with HCM have no obstruction
  (75)
• Majority of patients with obstruction have
  symptoms responsive to medical therapy
• Those with obstruction and unresponsive symptoms
  can be treated with septal ablation or
  myotomy-myectomy

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• No effect on
• Underlying pathology
• Myocardial disarray
• Small coronary artery abnormalities
• Diastolic dysfunction
• Associated mitral valve abnormalities
• Risk of sudden death
• Prognosis

• Effect on
• Outflow tract gradient
• Symptoms

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Procedure

• Temporary pacing wire
• Intermediate wire to S1
• OTW balloon inflated at origin of S1
• Wire removed, balloon inflated
• 3-5ml of absolute alcohol injected
• 5 minutes marination then balloon deflated

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Septal Ablation - Published Reports

• Knight et al Circulation 1997952075 18
  patients
• Faber et al Circulation 1998982415 91 patients
  
• Lakkis et al Circulation1998981750 33 patients
• Gietzen et al Eur Heart J 1999201342 50
  patients
• Kim et al Am J Cardiol 1999831220 20 patients
• Qin et al J Am Coll Cardiol 2001381994 25
  patients
• Total 237 patients

Longer term (7-36 month follow-up)

• Gietzen et al Eur Heart J 1999201342 37
  patients
• Faber et al Heart 200083326 25 patients
• Firoozi et al Eur Heart J 2002231617 20
  patients
• Shamin et al NEJM 2002 3471326 64 patients
• Total 146 patients

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Pre
Post
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Effect on Outflow Gradient

• All reports
• 65 mmHg pre
• 5 mmHg post
• Reduction in gradient sustained in long-term

Shamin et al N Engl J Med 20023471326
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Effect on Symptoms

• All reports show significant improvement
• Mean NYHA class pre 2.85, post 1.3
• Maintained over longer-term

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Effect on exercise

• 3 reports assessed peak O2 consumption (n104)
• 44 improvement
• 7 reports assessed exercise duration/watts
  (n204)
• 41 improvement
• Maintained at longer-term

Shamin et al N Engl J Med 20023471326
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Mortality

• Short-term 5/303 deaths (1.7)
• 2 in patients with severe pulmonary disease
• 1 pulmonary embolus (line-related DVT)
• 1 sudden AV block day 4
• 1 sudden out-of hospital (?AV block)
• Long-term 1 further death (pancreatic carcinoma)

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Heart-Block

• Overall rate is 20 requiring PPM
• Ranges from 0-40
• Incidence appears to be reducing (contrast echo)
• 10 of surgical patients require PPM
• Beneficial effects of procedure similar in
  paced/not paced patients

Shamin et al N Engl J Med 20023471326
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Arrhythmias

• Early VF in 1.6
• No late arrhythmias reported

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Late Ventricular Dilatation

• Information from 134 patients
• (4 reports)
• 4.2mm Pre
• 4.7mm Post

Shamin et al N Engl J Med 20023471326
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Comparison with Surgery

• No randomised studies
• Two recent non-randomised comparisons
• St Georges Hospital
• Cleveland Clinic
• Patients well matched but septal ablation
  patients older and more co-morbidity

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Cleveland Clinic
St. Georges
Firoozi et al Eur Heart J 2002231617
Qin et al JACC 2001381994
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Conclusions

• Still limited data
• Not profoundly aggressive
• Results similar to surgery
• Mortality and morbidity acceptable and similar to
  surgery
• Should be performed as part of a HCM service by
  experienced operators
• Patient selection of paramount importance