Age-Related Hemodynamic and Morphologic Differences in Patients Undergoing Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy

Abstract

Background Alcohol septal ablation (ASA) decreases the left ventricular (LV) outflow gradient and relieves symptoms in patients with highly symptomatic hypertrophic obstructive cardiomyopathy (HOCM). The aim of this study was to evaluate the early course of hemodynamic, morphologic and clinical changes in younger and elderly patients. Methods and Results Forty-four consecutive patients (age, 24-81 years) underwent the ASA procedure for HOCM. Clinical and echocardiographic data were obtained at baseline and periodically up to 12 months after ASA. There was a significant correlation between septum thickness and age at baseline and in the early post procedural period (p=0.004 at baseline, p=0.0033 days postoperative, p=0.0193 weeks pos operative). The dependence of septal thickness on the duration of follow-up (p<0.001) was significantly influenced by age (p=0.026), which retained statistical significance after multivariate adjustment (p=0.031). A decrease in the gradient of the LV outflow was identified in all age-related groups of patients (p<0.001). After multivariate adjustment, there was a significant influence of age (p=0.003) and creatine kinase-MB peak (p=0.016) on the course of outflow gradient reduction. Conclusions ASA is an effective treatment option for patients with HOCM, irrespective of their age. Younger patients are characterized by a thicker basal septum at baseline and a slower hemodynamic improvement within the early post procedural period. (Circ J 2006; 70: 880 -884)

Surgical Myectomy Remains the Primary Treatment Option for Severely Symptomatic Patients With Obstructive Hypertrophic Cardiomyopathy

“…However, treatment failures have been reported in a substantial minority of patients 35,39,68 -71 (ie, up to 25%) 69 (Figure 6), particularly in those with large outflow gradients 69 ; induced complete heart block requiring permanent pacemaker dependency occurs in 5% to 33% of patients. 35,36,39,59 Emergence and Concerns…”

“…In addition, recognition that greatly elongated mitral valve leaflets can produce obstruction 55 (even after adequate myectomy) has led to valve repair or plication in some cases. 37,56 -58 Myectomy avoids mitral valve replacement 3,8,11,12,30 and can be regarded as a "pure" intervention, rarely leaving behind implanted devices (pacemakers and defibrillators) 3,5,11,59 and never potentially arrhythmogenic myocardial scarring. 60 The complexity and heterogeneity of outflow tract morphology (and necessity for the transaortic approach) have formulated the customary recommendation that septal myectomy be performed by surgeons having specific experience with this operation and HCM.…”

“…The benefit of alcohol septal ablation in older patients is similar to that in younger patients. 36,59 Because the risks of cardiac surgery, particularly stroke, increase with age, ablation may offer an advantage in older patients. 3.…”

Survival After Alcohol Septal Ablation for Obstructive Hypertrophic Cardiomyopathy

“…28,29 Given that suboptimal outcomes with septal ablation in relatively younger patients have been observed in some studies, consideration has been given to surgical myectomy as the preferred method for septal reduction therapy in this population, especially those Ͻ40 years of age. 4,21,28,30,31 Nevertheless, it is important to note that this study did not examine potential impact of subacute remodeling and changes in LVOT gradient in follow-up on long-term outcome.…”

2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: Executive Summary

“…The benefit of alcohol septal ablation in patients of advanced age is similar to that in other patients. 127,305 Because the postoperative risks and complications of cardiac surgery increase with age, ablation may offer a selective advantage in older patients, in whom operative risk may be increased because of comorbidities. Alcohol septal ablation is not indicated in children.…”