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Percutaneous Septal Ablation in Hypertrophic Obstructive Cardiomyopathy: From Experiment to Standard of Care.

Faber L - Adv Med (2014)

Bottom Line: Correct diagnosis and risk stratification with respect to prophylactic ICD implantation are essential in HCM patient management.Drug therapy in symptomatic patients can be characterized as treatment of heart failure with preserved ejection fraction (HFpEF) in HNCM, while symptoms and the obstructive gradient in HOCM can be addressed with beta-blockers, disopyramide, or verapamil.Literature data and the own series of about 600 cases are discussed, suggesting a largely comparable outcome with respect to procedural mortality, clinical efficacy, and long-term outcome.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, University Hospital of the Ruhr University Bochum, Georgstraße 11, 32545 Bad Oeynhausen, Germany.

ABSTRACT
Hypertrophic cardiomyopathy (HCM) is one of the more common hereditary cardiac conditions. According to presence or absence of outflow obstruction at rest or with provocation, a more common (about 60-70%) obstructive type of the disease (HOCM) has to be distinguished from the less common (30-40%) nonobstructive phenotype (HNCM). Symptoms include exercise limitation due to dyspnea, angina pectoris, palpitations, or dizziness; occasionally syncope or sudden cardiac death occurs. Correct diagnosis and risk stratification with respect to prophylactic ICD implantation are essential in HCM patient management. Drug therapy in symptomatic patients can be characterized as treatment of heart failure with preserved ejection fraction (HFpEF) in HNCM, while symptoms and the obstructive gradient in HOCM can be addressed with beta-blockers, disopyramide, or verapamil. After a short overview on etiology, natural history, and diagnostics in hypertrophic cardiomyopathy, this paper reviews the current treatment options for HOCM with a special focus on percutaneous septal ablation. Literature data and the own series of about 600 cases are discussed, suggesting a largely comparable outcome with respect to procedural mortality, clinical efficacy, and long-term outcome.

No MeSH data available.


Related in: MedlinePlus

Echocardiographic aspect of HOCM before/after a myectomy ((a)–(d)) and after a percutaneous septal ablation ((e)–(h)). Both cases show marked thickening of the midcavity and subaortic septum (arrows in (a) and (e)) at baseline together with a substantial outflow acceleration to >5 m/s corresponding to an outflow gradient of 100 mm Hg at rest ((b) and (f)). After the respective intervention there is thinning of the subaortic septum (arrows in (c) and (g)) and normalisation of LV outflow to <2 m/s, that is, absence of a resting gradient. The different ECG patterns of QRS widening with a LBBB pattern in C/D after myectomy and a RBBB pattern after septal ablation are also visible. LA: left atrium; RA: right atrium; RV: right ventricle; and LV: left ventricle.
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fig6: Echocardiographic aspect of HOCM before/after a myectomy ((a)–(d)) and after a percutaneous septal ablation ((e)–(h)). Both cases show marked thickening of the midcavity and subaortic septum (arrows in (a) and (e)) at baseline together with a substantial outflow acceleration to >5 m/s corresponding to an outflow gradient of 100 mm Hg at rest ((b) and (f)). After the respective intervention there is thinning of the subaortic septum (arrows in (c) and (g)) and normalisation of LV outflow to <2 m/s, that is, absence of a resting gradient. The different ECG patterns of QRS widening with a LBBB pattern in C/D after myectomy and a RBBB pattern after septal ablation are also visible. LA: left atrium; RA: right atrium; RV: right ventricle; and LV: left ventricle.

Mentions: Surgical myectomy, developed in the late fifth and the sixth decade of the 20th century, traditionally has been the treatment of choice for HCM patients with drug-refractory symptoms and significant outflow obstruction [87–97]. The procedure aims at removing a part of the protruding septal myocardium (Figure 3) via a transaortic approach and leaves a clearly visible septal trough on imaging studies (Figure 4) and usually a left bundle-branch block on the surface ECG in >50% of the patients treated (Figure 6). The depth and extent of septal resection can be tailored to the individual anatomy, thus also addressing midcavity obstruction or papillary muscle abnormalities if present. Furthermore, valvular correction/replacement or coronary bypass grafting can be combined with the reduction of septal myocardium if necessary. Perioperative monitoring by transesophageal echocardiography has become a routine procedure. The rate of pacemaker dependency is reported to be ≤5%.


Percutaneous Septal Ablation in Hypertrophic Obstructive Cardiomyopathy: From Experiment to Standard of Care.

Faber L - Adv Med (2014)

Echocardiographic aspect of HOCM before/after a myectomy ((a)–(d)) and after a percutaneous septal ablation ((e)–(h)). Both cases show marked thickening of the midcavity and subaortic septum (arrows in (a) and (e)) at baseline together with a substantial outflow acceleration to >5 m/s corresponding to an outflow gradient of 100 mm Hg at rest ((b) and (f)). After the respective intervention there is thinning of the subaortic septum (arrows in (c) and (g)) and normalisation of LV outflow to <2 m/s, that is, absence of a resting gradient. The different ECG patterns of QRS widening with a LBBB pattern in C/D after myectomy and a RBBB pattern after septal ablation are also visible. LA: left atrium; RA: right atrium; RV: right ventricle; and LV: left ventricle.
© Copyright Policy - open-access
Related In: Results  -  Collection

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getmorefigures.php?uid=PMC4590958&req=5

fig6: Echocardiographic aspect of HOCM before/after a myectomy ((a)–(d)) and after a percutaneous septal ablation ((e)–(h)). Both cases show marked thickening of the midcavity and subaortic septum (arrows in (a) and (e)) at baseline together with a substantial outflow acceleration to >5 m/s corresponding to an outflow gradient of 100 mm Hg at rest ((b) and (f)). After the respective intervention there is thinning of the subaortic septum (arrows in (c) and (g)) and normalisation of LV outflow to <2 m/s, that is, absence of a resting gradient. The different ECG patterns of QRS widening with a LBBB pattern in C/D after myectomy and a RBBB pattern after septal ablation are also visible. LA: left atrium; RA: right atrium; RV: right ventricle; and LV: left ventricle.
Mentions: Surgical myectomy, developed in the late fifth and the sixth decade of the 20th century, traditionally has been the treatment of choice for HCM patients with drug-refractory symptoms and significant outflow obstruction [87–97]. The procedure aims at removing a part of the protruding septal myocardium (Figure 3) via a transaortic approach and leaves a clearly visible septal trough on imaging studies (Figure 4) and usually a left bundle-branch block on the surface ECG in >50% of the patients treated (Figure 6). The depth and extent of septal resection can be tailored to the individual anatomy, thus also addressing midcavity obstruction or papillary muscle abnormalities if present. Furthermore, valvular correction/replacement or coronary bypass grafting can be combined with the reduction of septal myocardium if necessary. Perioperative monitoring by transesophageal echocardiography has become a routine procedure. The rate of pacemaker dependency is reported to be ≤5%.

Bottom Line: Correct diagnosis and risk stratification with respect to prophylactic ICD implantation are essential in HCM patient management.Drug therapy in symptomatic patients can be characterized as treatment of heart failure with preserved ejection fraction (HFpEF) in HNCM, while symptoms and the obstructive gradient in HOCM can be addressed with beta-blockers, disopyramide, or verapamil.Literature data and the own series of about 600 cases are discussed, suggesting a largely comparable outcome with respect to procedural mortality, clinical efficacy, and long-term outcome.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, University Hospital of the Ruhr University Bochum, Georgstraße 11, 32545 Bad Oeynhausen, Germany.

ABSTRACT
Hypertrophic cardiomyopathy (HCM) is one of the more common hereditary cardiac conditions. According to presence or absence of outflow obstruction at rest or with provocation, a more common (about 60-70%) obstructive type of the disease (HOCM) has to be distinguished from the less common (30-40%) nonobstructive phenotype (HNCM). Symptoms include exercise limitation due to dyspnea, angina pectoris, palpitations, or dizziness; occasionally syncope or sudden cardiac death occurs. Correct diagnosis and risk stratification with respect to prophylactic ICD implantation are essential in HCM patient management. Drug therapy in symptomatic patients can be characterized as treatment of heart failure with preserved ejection fraction (HFpEF) in HNCM, while symptoms and the obstructive gradient in HOCM can be addressed with beta-blockers, disopyramide, or verapamil. After a short overview on etiology, natural history, and diagnostics in hypertrophic cardiomyopathy, this paper reviews the current treatment options for HOCM with a special focus on percutaneous septal ablation. Literature data and the own series of about 600 cases are discussed, suggesting a largely comparable outcome with respect to procedural mortality, clinical efficacy, and long-term outcome.

No MeSH data available.


Related in: MedlinePlus