Alcohol Septal Ablation or Septal Myectomy? An Updated Systematic Review and Meta-Analysis of Septal Reduction Therapy for Hypertrophic Obstructive Cardiomyopathy

Abstract

ObjectiveTo evaluate the safety and effectiveness of alcohol septal ablation (ASA) and septal myectomy (SM) for the treatment of hypertrophic obstructive cardiomyopathy.MethodsWe searched the PubMed, MEDLINE, EMBASE, and CBM databases for observational research articles related to ASA and SM published from the establishment of the databases to November 2021. All ultimate selected articles were highly related to our target. The Newcastle-Ottawa Scale was used to evaluate the literature quality. A fixed or random effect model was performed in the meta-analysis depending on the heterogeneity of the included studies. The Mantel-Haenszelt test with relative risk ratio (RR) and 95% confidence interval (CI) was used to measure the effect indicator of binary data, while the inverse variance method with weighted mean difference (WMD) and 95% CI was used to measure the effect indicator of continuous data.ResultsA totally of 3,647 cases (1,555 cases treated with ASA and 2,092 cases treated with SM) were included. The results of the systematic review indicated no statistically significant difference in postoperative all-cause mortality (RR = 0.82; 95% CI: 0.65–1.04; P = 0.10) between patients treated with ASA and SM, but both the reduction in the postoperative left ventricular outflow tract pressure gradient (WMD = 9.35 mmHg, 95% CI: 5.38–13.31, P < 0.00001) and the post-operative improvement on cardiac function, assessed by the grade of New York Heart Association (NYHA), compared to pre-operative measurements (WMD = 0.13; 95% CI: 0.00–0.26; P < 0.04) in the ASA group were slightly inferior to those in the SM group. In addition, both the risk of pacemaker implantation (RR = 2.83, 95% CI: 2.06–3.88; P < 0.00001) and the risk of reoperation (RR = 11.23, 95% CI: 6.21–20.31; P < 0.00001) are recorded at a higher level after ASA procedure.ConclusionBoth ASA and SM have a high degree of safety, but the reduction in the postoperative left ventricular outflow tract pressure gradient and the improvement on cardiac function are slightly inferior to SM. In addition, both the risk of pacemaker implantation and the risk of reoperation are recorded at a higher level after ASA procedure. The operative plan should be chosen through multidisciplinary discussions in combination with the wishes of the patients and the actual clinical situation.

A case report of percutaneous intramyocardial septal radiofrequency ablation in an adult with re-obstruction after Morrow procedure

“…The possibility of conduction block and inadequate ablation is higher, especially for patients with existing bundle branch conduction block. 6 Therefore, after comprehensive evaluation by a multi-disciplinary team, PIMSRA, which is less invasive and equipped with electrocardiographic protection, was chosen. This was also the first patient with congenital MGA combined with HCM to be treated with PIMSRA after Morrow procedure.…”

Global research trends of hypertrophic cardiomyopathy from 2000 to 2022: Insights from bibliometric analysis

“…It has a definite curative effect in clinical practice and is considered the gold-standard treatment for medically refractory obstructive HCM. For elderly patients with chronic diseases who cannot tolerate SM operation, the ASA procedure is a relatively effective and safe alteration ( 36 , 37 ). Besides the traditional operations mentioned above, it is worth noting that an innovative type of surgery named the Liwen procedure has been proposed by Chinese clinicians in recent years.…”

Alcohol septal ablation in hypertrophic cardiomyopathy: For which patients?

“…A following meta‐analysis of 2013 patients who underwent ASA and were followed for an average of 6.2 years, the average reduction in LVOT gradient post‐ablation was 71%, and only 7.7% of patients ultimately required repeat intervention 22 . A more recent meta‐analysis presenting direct comparison of both strategies (1555 cases treated with ASA vs. 2092 cases treated with surgical myectomy) found no significant difference in postoperative all‐cause mortality (RR = 0.82; 95% CI: 0.65–1.04; P = 0.10), with a better LVOT gradient reduction and cardiac function improvement with surgical myectomy; unfortunately, data on any longer term outcomes was not provided 23 . The meta‐analysis of Liebregts et al therefore remains the last ‘gate‐keeper’ in terms of head‐to‐head comparison where outcomes over 5 years are offered (with a similar mortality 1.52% per year with ASA vs. 1.44% per year with surgical myectomy; P = 0.78) 22 .…”

“… 22 A more recent meta‐analysis presenting direct comparison of both strategies (1555 cases treated with ASA vs. 2092 cases treated with surgical myectomy) found no significant difference in postoperative all‐cause mortality (RR = 0.82; 95% CI: 0.65–1.04; P = 0.10), with a better LVOT gradient reduction and cardiac function improvement with surgical myectomy; unfortunately, data on any longer term outcomes was not provided. 23 The meta‐analysis of Liebregts et al therefore remains the last ‘gate‐keeper’ in terms of head‐to‐head comparison where outcomes over 5 years are offered (with a similar mortality 1.52% per year with ASA vs. 1.44% per year with surgical myectomy; P = 0.78). 22 Thus, it is immediately foreseen the need for an updated and robust cohort from which the two strategies would ideally be followed for up to 10 years.…”