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Septal ablation in Hypertrophic Cardiomyopathy

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Percutaneous transluminal septal myocardial ablation (PTSMA) Transcoronary ablation of septal hypertrophy (TASH) Septal ablation. Alcohol ablation ... – PowerPoint PPT presentation

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Title: Septal ablation in Hypertrophic Cardiomyopathy


1
Septal ablation in Hypertrophic Cardiomyopathy
Charles Knight London Chest Hospital Advanced
Angioplasty 2003
2
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

3
  • 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
4
Myotomy-myectomy
5
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

6
  • 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

7
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

8
(No Transcript)
9
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

10
Pre
Post
11
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
12
Effect on Symptoms
  • All reports show significant improvement
  • Mean NYHA class pre 2.85, post 1.3
  • Maintained over longer-term

13
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
14
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)

15
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
16
Arrhythmias
  • Early VF in 1.6
  • No late arrhythmias reported

17
Late Ventricular Dilatation
  • Information from 134 patients
  • (4 reports)
  • 4.2mm Pre
  • 4.7mm Post

Shamin et al N Engl J Med 20023471326
18
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

19
Cleveland Clinic
St. Georges
Firoozi et al Eur Heart J 2002231617
Qin et al JACC 2001381994
20
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
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