Outcomes of Patients With Hypertrophic Obstructive Cardiomyopathy and Pacemaker Implanted After Alcohol Septal Ablation

Veselka, Josef; Liebregts, Max; Cooper, Robert; Faber, Lothar; Januška, Jaroslav; Kashtanov, Maksim; Tesárková, Klára Hulíková; Hansen, Peter Riis; Seggewiß, Hubert; Shloydo, Eugene; Popov, Kirill; Hansvenclová, Eva; Bonaventura, Jiří; Berg, Jurriën Ten; Stables, Rodney H; Poláková, Eva

doi:10.1016/j.jcin.2022.06.034

Cited by 16 publications

(3 citation statements)

References 16 publications

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“…In this study, the amount of alcohol injected during the procedure was not associated with remaining LVOTO at follow-up. The mean amount of alcohol injected during the ASA in this study (1.6 ± 0.3 mL) is lower than in previous studies reporting mean alcohol doses of 2.1-2.2 mL [14]. However, the BSWT this study was lower (mean 19 mm) than in the study for comparison (20.1-20.7 mm).…”

Section: Discussioncontrasting

confidence: 79%

Alcohol septal ablation in hypertrophic obstructive cardiomyopathy: do sex, mitral valve leaflet length and septal thickness affect the outcome?

Mustafic,

Jandér,

Marlevi

et al. 2024

Preprint

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PurposeThis retrospective cohort study aimed to assess whether basal septal wall thickness (BSWT), anterior (AML) and posterior (PML) mitral leaflet length, or sex were associated with remaining left ventricular outflow tract obstruction (LVOTO) in patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing alcohol septal ablation (ASA).Methods154 patients that underwent ASA at the Karolinska University Hospital in Stockholm, Sweden, between 2009 and 2021, were retrospectively included. Anatomical and hemodynamic parameters were collected from invasive catheterization before and during ASA, and from echocardiography (ECHO) examinations before, during, and at one-year follow-up after ASA. Linear and logistic regression models were used to assess the association between sex, BSWT, AML, PML, and outcome defined as remaining LVOTO (>30 mmHg) after ASA.ResultsThe median follow-up was 364 days (IQR 334-385 days). BSWT>23 mm (n=13, 12%) was associated with remaining LVOTO at follow-up (p=0.004). Elongated MVLL (either AML or PML) was present in 125 (90%) of the patients. Elongated AML (>24 mm) was present in 67 (44%) of the patients, although AML length was not associated with remaining LVOTO at follow-up. Elongated PML (>14 mm) was present in 114 (74%) and not associated with remaining LVOTO at follow-up. No significant sex differences were observed regarding remaining LVOTO.ConclusionECHO measurement of BSWT can be used effectively for patient selection for successful ASA and for identification of patients with a risk of incomplete resolution of LVOTO after ASA.

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Section: Discussioncontrasting

confidence: 79%

Alcohol septal ablation in hypertrophic obstructive cardiomyopathy: do sex, mitral valve leaflet length and septal thickness affect the outcome?

Mustafic,

Jandér,

Marlevi

et al. 2024

Preprint

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“…18 Once again, there have been no prospective trials of ASA for this indication, and a trial of PPoP prior to ASA may be warranted in the context of baseline ICD indications and the high risk of ASA-related conduction disease. 24…”

Section: Discussionmentioning

confidence: 99%

Distal Ventricular Pacing for Drug-Refractory Mid-Cavity Obstructive Hypertrophic Cardiomyopathy: A Randomized, Placebo-Controlled Trial of Personalized Pacing

Malcolmson,

Hughes,

Husselbury

et al. 2023

Preprint

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BackgroundPatients with refractory symptomatic left ventricular (LV) mid-cavity obstructive (LVMCO) hypertrophic cardiomyopathy (HCM) have few therapeutic options. Right ventricular (RV) pacing is associated with modest hemodynamic and symptomatic improvement, and LV pacing pilot data suggest therapeutic potential. We hypothesized site-specific-pacing would reduce LVMCO gradients and improve symptoms.MethodsPatients with symptomatic-drug-refractory LVMCO were recruited for a randomized blinded trial of personalized prescription of pacing (PPoP). Multiple LV and apical RV pacing sites were assessed during invasive hemodynamic study of multisite pacing. Patient-specific pacing-site and atrioventricular (AV) delays, defining PPoP, were selected on basis of LVMCO gradient reduction and acceptable pacing parameters. Patients were randomized to 6-months of active PPoP or back-up pacing in a cross-over design. The primary outcome examined invasive gradient change with best-site pacing. Secondary outcomes assessed quality of life and exercise following randomization to PPoP.ResultsA total of 17 patients were recruited; 16 of whom met primary endpoints. Baseline NYHA was 3±0.6 despite optimal medical therapy. Hemodynamic effects were assessed during pacing at the RV apex and at a mean of 8 LV sites. The gradients in all 16 patients fell with pacing, with maximum gradient reduction achieved via LV pacing in 14 (88%) patients and RV apex in 2. The mean baseline gradient of 80±29 mmHg, fell to 31±21 mmHg with best-site pacing, a 60% reduction (p<0.0001). One cardiac vein perforation occurred in one case, and 15 subjects entered cross-over; 2 withdrawals occurred during cross-over. Of the 13 completing cross-over, 9 (69%) chose active pacing in PPoP configuration as preferred setting. PPoP was associated with improved 6-minute walking test performance (328.5±99.9 vs 285.8±105.5 meters, p=0.018); other outcome measures also indicated benefit with PPoP.ConclusionsIn a randomized placebo-controlled trial, LV pacing reduces obstruction and improves exercise performance in severely symptomatic LVMCO patients.RegistrationNCT03450252.Clinical PerspectiveWhat is Known?Patients with refractory, symptomatic LVMCO present a significant challenge for clinical management, with very few treatment options.Data on the use of right ventricular (RV) pacing in patients with refractory, symptomatic LVMCO indicate suboptimal therapeutic responses whilst pilot data indicate a potential therapeutic role for LV pacing.What the Study Adds?Personalized prescription of pacing (PPoP) therapy guided by invasive hemodynamics significantly reduced LVMCO gradients and improved exercise performance in the first randomized, placebo-controlled trial in symptomatic LVMCO.This study provides the basis for a multicenter trial of PPoP for LVMCO and for the use of site-specific pacing in managing other forms of HCM.Graphical Abstract

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“…18 Once again, there have been no prospective trials of ASA for this indication, and a trial of PPoP before ASA may be warranted in the context of baseline ICD indications and the high risk of ASA-related conduction disease. 24…”

Section: Alcohol Septal Ablationmentioning

confidence: 99%

Distal Ventricular Pacing for Drug-Refractory Mid-Cavity Obstructive Hypertrophic Cardiomyopathy: A Randomized, Placebo-Controlled Trial of Personalized Pacing

Malcolmson,

Hughes,

Husselbury

et al. 2024

Circ: Arrhythmia and Electrophysiology

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BACKGROUND: Patients with refractory, symptomatic left ventricular (LV) mid-cavity obstructive (LVMCO) hypertrophic cardiomyopathy have few therapeutic options. Right ventricular pacing is associated with modest hemodynamic and symptomatic improvement, and LV pacing pilot data suggest therapeutic potential. We hypothesized that site-specific pacing would reduce LVMCO gradients and improve symptoms. METHODS: Patients with symptomatic-drug-refractory LVMCO were recruited for a randomized, blinded trial of personalized prescription of pacing (PPoP). Multiple LV and apical right ventricular pacing sites were assessed during an invasive hemodynamic study of multisite pacing. Patient-specific pacing-site and atrioventricular delays, defining PPoP, were selected on the basis of LVMCO gradient reduction and acceptable pacing parameters. Patients were randomized to 6 months of active PPoP or backup pacing in a crossover design. The primary outcome examined invasive gradient change with best-site pacing. Secondary outcomes assessed quality of life and exercise following randomization to PPoP. RESULTS: A total of 17 patients were recruited; 16 of whom met primary end points. Baseline New York Heart Association was 3±0.6, despite optimal medical therapy. Hemodynamic effects were assessed during pacing at the right ventricular apex and at a mean of 8 LV sites. The gradients in all 16 patients fell with pacing, with maximum gradient reduction achieved via LV pacing in 14 (88%) patients and right ventricular apex in 2. The mean baseline gradient of 80±29 mm Hg fell to 31±21 mm Hg with best-site pacing, a 60% reduction ( P <0.0001). One cardiac vein perforation occurred in 1 case, and 15 subjects entered crossover; 2 withdrawals occurred during crossover. Of the 13 completing crossover, 9 (69%) chose active pacing in PPoP configuration as preferred setting. PPoP was associated with improved 6-minute walking test performance (328.5±99.9 versus 285.8±105.5 m; P =0.018); other outcome measures also indicated benefit with PPoP. CONCLUSIONS: In a randomized placebo-controlled trial, PPoP reduces obstruction and improves exercise performance in severely symptomatic patients with LVMCO. REGISTRATION: URL: https://clinicaltrials.gov ; Unique Identifier: NCT03450252.

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Outcomes of Patients With Hypertrophic Obstructive Cardiomyopathy and Pacemaker Implanted After Alcohol Septal Ablation

Cited by 16 publications

References 16 publications

Alcohol septal ablation in hypertrophic obstructive cardiomyopathy: do sex, mitral valve leaflet length and septal thickness affect the outcome?

Alcohol septal ablation in hypertrophic obstructive cardiomyopathy: do sex, mitral valve leaflet length and septal thickness affect the outcome?

Distal Ventricular Pacing for Drug-Refractory Mid-Cavity Obstructive Hypertrophic Cardiomyopathy: A Randomized, Placebo-Controlled Trial of Personalized Pacing

Distal Ventricular Pacing for Drug-Refractory Mid-Cavity Obstructive Hypertrophic Cardiomyopathy: A Randomized, Placebo-Controlled Trial of Personalized Pacing

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