Impact of Septal Reduction on Left Atrial Size and Diastole in Hypertrophic Cardiomyopathy

Finocchiaro, Gherardo; Haddad, François; Kobayashi, Yukari; Lee, David; Pavlović, Aleksandra; Schnittger, Ingela; Sinagra, Gianfranco; Magavern, Emma; Myers, Jonathan A.; Froelicher, Victor; Knowles, Joshua; Ashley, Euan A.

doi:10.1111/echo.13158

Cited by 27 publications

(18 citation statements)

References 27 publications

(33 reference statements)

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“…1 Septal myectomy relieves the left ventricular (LV) outflow tract obstruction (LVOTO) and is associated with excellent long-term outcomes. [7][8][9][10][11][12] Two-dimensional (2D) speckle-tracking echocardiography (2DSTE) allows measurement of phasic changes in LA volumes and strain. One would expect improvement of these parameters following elimination of the LVOTO by surgical myectomy.…”

Section: Introductionmentioning

confidence: 99%

“…However, data regarding diastolic and LA function post myectomy are scarce and inconsistent. [7][8][9][10][11][12] Two-dimensional (2D) speckle-tracking echocardiography (2DSTE) allows measurement of phasic changes in LA volumes and strain. 13,14 Furthermore, 2DSTE-derived LA functional parameters have been strongly associated with the degree of diastolic dysfunction.…”

Section: Introductionmentioning

confidence: 99%

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Left atrial remodeling postseptal myectomy for severe obstructive hypertrophic cardiomyopathy: Analysis by two‐dimensional speckle‐tracking echocardiography

et al. 2019

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Background: Septal myectomy relieves left ventricular outflow obstruction (LVOTO) and is associated with excellent long-term outcomes. LVOTO is associated with diastolic dysfunction and increased left atrial (LA) size. We sought to investigate the changes in LA volumes and function post myectomy and the association between these changes with clinical outcomes post myectomy.Methods: Sixty-six hypertrophic cardiomyopathy patients undergoing myectomy were retrospectively studied. Pre procedural and 6-to 18-month post myectomy follow-up transthoracic echocardiographic images were obtained. LA volumes and strain were assessed by two-dimensional speckle-tracking echocardiography.Results: Left atrial volumes, that is, indexed maximal, minimal, and pre-A volumes reduced post myectomy, yet remained increased compared to controls (105.6 ± 34.5 mL vs 84.9 ± 26.7 mL, 45.2 ± 25.7 mL vs 35.4 ± 22.6 mL, 70.1 ± 31.4 mL vs 35.4 ± 22.6 mL, respectively, P < 0.05). The total emptying index did not improve post myectomy and remained lower than controls (58.6 ± 12.4 vs 59.9 ± 12.8, P = NS) whereas atrial contraction improved, yet did not normalize (active emptying index 36.1 ± 14.9 vs 41.1 ± 16.2, P < 0.05).The conduit volume remained reduced post myectomy (18.6 ± 13.3 mL vs 16.6 ± 15.1 mL, P = NS). LA strain also did not improve post myectomy (26.8 ± 7.3 vs 28.5 ± 8.8, P = NS). A multivariable logistic regression identified pre procedural E/e′ ratio and indexed maximal LA volume, as independent predictors for LA volume reduction ≥20% post myectomy. During a mean follow-up of 4.9 ± 2.3 years post myectomy, 24.2% of the patients developed atrial fibrillation and <5% of patients were severely symptomatic. We found no associations between LA volumes/function and atrial fibrillation or symptoms post myectomy. Conclusion:Postmyectomy LA volumes decreased, and the contractile function improved. There was no association between LA volumes/function and clinical outcomes post myectomy. Notably, the LA remained enlarged (though to a lesser degree) with reduced strain and emptying fraction, suggesting possible atrial myopathy. K E Y W O R D Shypertrophic obstructive cardiomyopathy, left atrial function, left atrial volume, myectomy, two-dimensional speckle-tracking echocardiography | 277 WEISSLER-SNIR Et aL.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Left atrial remodeling postseptal myectomy for severe obstructive hypertrophic cardiomyopathy: Analysis by two‐dimensional speckle‐tracking echocardiography

et al. 2019

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“…Of 7638 articles identified in the initial searches, 645 studies were considered as potentially relevant. After a stringent selection process, 20 articles met the inclusion criteria [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 ]. Two of them were CTs [ 31 , 33 ] and 18 cohort studies [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 32 , 34 , 35 , 36 , 37 ].…”

Section: Resultsmentioning

confidence: 99%

Alcohol Septal Ablation versus Septal Myectomy Treatment of Obstructive Hypertrophic Cardiomyopathy: A Systematic Review and Meta-Analysis

Bytyçi

Nistri²,

Mörner

et al. 2020

JCM

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Surgical myectomy (SM) and alcohol septal ablation (ASA) are two invasive therapies for symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM), despite medical therapy. This meta-analysis aims to compare the efficacy of the two procedures. We searched all electronic databases until February 2020 for clinical trials and cohorts comparing clinical outcomes of ASA and SM treatment of patients with HOCM. The primary endpoint was all-cause mortality, cardiovascular (CV) mortality, sudden cardiac death (SCD), re-intervention, and complications. Secondary endpoints included relief of clinical symptoms and drop of left ventricular outflow tract (LVOT) gradient. Twenty studies (4547 patients; 2 CTs and 18 cohorts) comparing ASA vs. SM with a mean follow-up of 47 ± 28.7 months were included. Long term (8.72 vs. 7.84%, p = 0.42) and short term (1.12 vs. 1.27%, p = 0.93) all-cause mortality, CV mortality (2.48 vs. 3.66%, p = 0.26), SCD (1.78 vs. 0.76%, p = 0.20) and stroke (0.36 vs. 1.01%, p = 0.64) were not different between procedures. ASA was associated with lower peri-procedural complications (5.57 vs. 10.5%, p = 0.04) but higher rate of re-interventions (10.1 vs. 0.27%; p < 0.001) and pacemaker dependency (12.4 vs. 4.31%, p = 0.0004) compared to SM. ASA resulted in less reduction in LVOT gradient (−47.8 vs. −58.4 mmHg, p = 0.01) and less improvement of clinical symptoms compared to SM (New York Heart Association (NYHA) class III/IV, 82.4 vs. 94.5%, p < 0.001, angina 53.2 vs. 84.2%, p = 0.02). Thus, ASA and SM treatment of HOCM carry a similar risk of mortality. Peri-procedural complications are less in alcohol ablation but re-intervention and pacemaker implantations are more common. These results might impact the procedure choice in individual patients, for the best clinical outcome.

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“…The reduction in LA volume after myectomy in our population suggests an improvement in diastolic intraventricular pressures, this study however did not demonstrate improvement in global or regional diastolic function, which might be explained by the reduced LV compliance [ 37 ]. Accordingly, an echocardiographic study also revealed reduction in LA volume without improvement in diastolic function and might be related to the disease history and increased development of interstitial fibrosis [ 12 ]. Summarizing, our findings we demonstrate reversed structural remodeling after myectomy, and worsening of functional remodeling at the septum.…”

Section: Discussionmentioning

confidence: 99%

Myocardial adaptation after surgical therapy differs for aortic valve stenosis and hypertrophic obstructive cardiomyopathy

Parbhudayal

Güçlü

Zweerink

et al. 2019

Int J Cardiovasc Imaging

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Surgical therapies in aortic valve stenosis (AVS) and hypertrophic obstructive cardiomyopathy (HOCM) aim to relief intraventricular pressure overload and improve clinical outcome. It is currently unknown to what extent myocardial adaptation concurs with restoration of intraventricular pressures, and whether this is similar in both patient groups. The aim of this study was to investigate changes in myocardial adaptation after surgical therapies for AVS and HOCM. Ten AVS and ten HOCM patients were enrolled and underwent cardiac magnetic resonance cine imaging and myocardial tagging prior to, and 4 months after aortic valve replacement (AVR) and septal myectomy, respectively. Global left ventricular (LV) analyses were derived from cine images. Circumferential strain was assessed from myocardial tagging images at the septal and lateral wall of the mid ventricle. Pressure gradients significantly decreased in both AVS and HOCM after surgery ( p < 0.01), with a concomitant decrease in left atrial volume ( p < 0.05) suggesting lower diastolic filling pressures. Also, LV volumes, mass and septal wall thickness decreased in both, but to a larger extent in AVS than in HOCM patients. AVR improved wall thickening ( p < 0.05) and did not change systolic strain rate. Myectomy did not affect wall thickening and reduced septal systolic strain rate ( p = 0.03). Both AVR and myectomy induced positive structural remodeling in line with a reduction of pressure overload. A concomitant recovery in systolic function however was found in AVR only. The systolic functional deterioration in HOCM patients seems to be inherent to myectomy and the ongoing and irreversible disease. Electronic supplementary material The online version of this article (10.1007/s10554-019-01563-3) contains supplementary material, which is available to authorized users.

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Impact of Septal Reduction on Left Atrial Size and Diastole in Hypertrophic Cardiomyopathy

Abstract: Septal reduction is effective in the relief of LV obstruction and symptoms in patients with HCM. The hemodynamic changes result in a significant LA reverse remodeling, but not in an improvement of diastolic function in these patients.

Cited by 27 publications

References 27 publications

Left atrial remodeling postseptal myectomy for severe obstructive hypertrophic cardiomyopathy: Analysis by two‐dimensional speckle‐tracking echocardiography

Left atrial remodeling postseptal myectomy for severe obstructive hypertrophic cardiomyopathy: Analysis by two‐dimensional speckle‐tracking echocardiography

Alcohol Septal Ablation versus Septal Myectomy Treatment of Obstructive Hypertrophic Cardiomyopathy: A Systematic Review and Meta-Analysis

Myocardial adaptation after surgical therapy differs for aortic valve stenosis and hypertrophic obstructive cardiomyopathy

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