A prospective follow-up of alcohol septal ablation for symptomatic hypertrophic obstructive cardiomyopathy--the Baylor experience (1996-2002)

BACKGROUND: There is a paucity of data on the long-term outcome of alcohol septal ablation (ASA) for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). HYPOTHESIS: The study was undertaken to evaluate the longer-term outcome of ASA therapy for symptomatic HOCM. METHODS: In all, 137 patients were enrolled consecutively (1996-1999) and 130 (95%) (74 men, 56 women, aged 51 +/- 17 years) underwent ASA and had serial prospective follow-up for up to 5 years (mean follow-up 3.6 +/- 1.4 years). Evaluation included angina (Canadian Cardiovascular Society [CCS] score), dyspnea (New York Heart Association [NYHA] class), duration of exercise on treadmill, and echocardiographic indices. RESULTS: Ethanol (3.5 +/- 1.5 cc), injected into 1.5 +/- 0.6 arteries, induced a mean peak plasma creatine kinase (CK) of 1676 +/- 944 units. Complications of procedures included death 1.5% (2/130), heart block requiring permanent pacemaker 13% (17/130), and coronary dissection 4.4% (6/130). Baseline versus last follow-up visit: NYHA class decreased from 3.0 +/- 0.4 to 1.2 +/- 0.6 (p < 0.01); CCS angina score from 2.0 +/- 0.8 to 0.08 +/- 0.4 (p < 0.01); and duration of exercise increased from 322 +/- 207 to 443 +/- 200 s (p < 0.01). Resting left ventricular outflow tract gradient at baseline versus last follow-up visit showed a decrease from 74 +/- 30 to 4 +/- 13 (p < 0.01), and the dobutamine-provoked gradient of 88 +/- 29 decreased to 21 +/- 21 (p < 0.01) mmHg. All-cause mortality over the duration of follow-up was 7.7% (10) giving an annual rate of 2.1%, and cardiac mortality was 2.3% (3) reflecting an annual rate of 0.6%. CONCLUSIONS: Alcohol septal ablation decreased symptoms and improved exercise performance, indicating that it is an effective procedure for symptomatic HOCM.     

Alcohol septal ablation for hypertrophic obstructive cardiomyopathy: a systematic review of published studies

OBJECTIVE: Alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM) has emerged as a lesser invasive alternative to surgical myectomy over the past decade. The purpose of this study is to analyze all the published literature on outcomes and complications after ASA. METHODS: MEDLINE and PubMed were searched for all available published literature on ASA (June 1996-June 2005) using the terms hypertrophic obstructive cardiomyopathy (HOCM), alcohol septal ablation for hypertrophic obstructive cardiomyopathy, alcohol septal ablation for HOCM, alcohol septal ablation (ASA), transcoronary alcohol septal ablation for hypertrophic obstructive cardiomyopathy (TASH), transcoronary alcohol septal ablation for HOCM, nonsurgical septal reduction therapy (NSRT), and percutaneous transcoronary septal myocardial ablation (PTSMA). RESULTS: A total of 42 published studies (2,959 patients) were analyzed. Mean age was 53.5 (35.4-72) years with a mean male to female ratio of 1.17. Mean follow-up was 12.7 +/- 0.3 months (1.5-43.2). Absolute ethanol (3 mL) was injected in 1.2 septal perforator arteries. On average, serum CK peaked at 964 units. At 12 months, there was a sustained decrease in resting and provoked LVOT gradient (65.3-15.8 and 125.4-31.5 mmHg, respectively) accompanied by reduction in basal septal diameter (20.9-13.9 mm), improvement in NYHA Class (2.9-1.2), and increase in exercise capacity (325.3-437.5 seconds). Early mortality (within 30 days) was 1.5% (0.0-5.0%) and late mortality (beyond 30 days) was 0.5% (0.0-9.3%). Other complications include ventricular fibrillation (2.2%), LAD dissection (1.8%), complete heart block requiring permanent pacemaker (10.5%), and pericardial effusion (0.6%). A repeat ASA was performed on 6.6% of patients and 1.9% of patients underwent surgical myomectomy with resolution of symptoms. CONCLUSIONS: Literature to date suggests that ASA results in acute and intermediate-term favorable clinical and echocardiographic outcomes. A randomized controlled trial is needed to compare ASA and myomectomy in order to determine which technique provides maximal benefit.     

Electroanatomical Mapping‐Guided Endocardial and Epicardial Ablation of Sustained Ventricular Tachycardia Originating From Alcohol Septal Ablation‐Induced Scar in a Patient With Hypertrophic Obstructive Cardiomyopathy

Ventricular Tachycardia After Alcohol Septal Ablation. A 76‐year‐old female developed 2 different ventricular tachycardias (VTs) 5 years after alcohol septal ablation (ASA) for symptomatic hypertrophic obstructive cardiomyopathy. VT#1 was a small macroreentry at the anterior border of the low‐voltage zone, suggesting the ASA‐scar and eliminated by endocardial ablation at a site recording fractionated potentials covering the mid‐diastolic and presystolic periods. VT#2 was a focal VT and eliminated by epicardial cryoablation at the basal posterior left ventricle, suggesting the posterior border of the ASA‐scar. Using the electroanatomical mapping, we demonstrated that the mechanism of the VTs was reentry at the edge of the ASA‐scar. (J Cardiovasc Electrophysiol, Vol. 21, pp. 1296‐1299, November 2010)     

Simultaneous percutaneous treatment in hypertrophic obstructive cardiomyopathy and coronary artery disease: A case report

Percutaneous transluminal coronary angioplasty (PTCA) is an established therapy for coronary artery disease (CAD), whereas percutaneous transluminal septal myocardial ablation (PTSMA) is becoming increasingly significant in the therapy of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). We report the first ever simultaneous treatment, in a 62-yr-old patient, of significant HOCM and a 75% LAD stenosis from which the septal branch to be occluded stemmed. Using a double wire technique, first the septal branch was occluded through a fractional injection of 4 ml absolute alcohol, thus ablating the hypertrophied septal myocardium with reduction of the left ventricular outflow tract (LVOT) gradient at rest from 80 to 9 mmHg. Following this, the LAD stenosis was dilated and stented. Complications, in particular a trifascicular block or ventricular dysrhythmia, did not occur during the hospital stay. To conclude, combined PTSMA and PTCA may be considered as a therapeutic alternative to a combined surgical intervention in individual cases of symptomatic HOCM and CAD, provided that the potential complications are taken into account. Cathet. Cardiovasc. Diagn. 44:65–69, 1998. © 1998 Wiley-Liss, Inc.     

Percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: Acute results and three-year noninvasive follow-up in 18 patients

OBJECTIVES: To study the acute results and long-term clinical course after percutaneous transluminal septal myocardial ablation (PTSMA) in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). METHODS: In 18 patients (seven women, 11 men; average age 53+/-15 years) with symptomatic and medically refractory HOCM, 1.3+/-0.4 septal branches were occluded with an injection of 3.6+/-1.2 mL of 95% alcohol to ablate the hypertrophied interventricular septum. After three years, noninvasive follow-up results of clinical course, echocardiographic and electrocardiographic findings were determined. RESULTS: The invasively measured left ventricular outflow tract (LVOT) gradients were reduced in all patients, with a mean decrease from 79+/-21 mmHg to 11+/-8 mmHg at rest (P<0.01) and from 136+/-41 mmHg to 49+/-21 mmHg after extrasystole. All patients had angina pectoris for 8 h to 24 h. Eleven patients (61.1%) developed a trifascicular block for 3 min to four days requiring temporary (n=10 [56%]) or permanent dual chamber pacemaker implantation (n=1 [6%]). All patients were discharged after 5.9+/-2.3 days. Clinical, electrocardiographic and echocardiographic follow-up was achieved in all patients after three years (3.1+/-0.5 years). No cardiac complications occurred. Thirteen patients (72%) showed clinical improvement, with a New York Heart Association functional class of 1.5+/-0.8. A further reduction in LVOT gradient was shown in eight patients (44%). CONCLUSIONS: The LVOT gradient was greatly reduced in patients with HOCM undergoing a PTSMA procedure and their symptoms were greatly improved without cardiac complications during three-year follow-up. Possible complications include different degrees of heart block, such as trifascicular blocks, requiring temporary pacemaker implantation. PTSMA is a promising nonsurgical method for the treatment of symptomatic patients with HOCM. Clinical long-term follow-up of a larger series of patients is required to determine the therapeutic significance conclusively.     

Early outcomes of alcohol septal ablation for hypertrophic obstructive cardiomyopathy

Background: This study was designed to evaluate the outcomes of alcohol septal ablation (ASA) under multicenter and multinational conditions. Methods: Data for 459 patients (age 57 ± 13 years) from nine European centers were prospectively collected and retrospectively analyzed. Results: ASA led to a significant reduction in outflow gradient (PG) and dyspnea [median of PG from 88 (58–123) mm Hg to 21 (11–41) mm Hg; median of NYHA class from 3 (2–3) to 1 (1–2); P < 0.01]. The incidence of 3‐month major adverse events (death, electrical cardioversion for tachyarrhythmias, resuscitation) and mortality was 2.8% and 0.7%, respectively. Permanent pacemakers for post‐ASA complete heart block were implanted in 43 patients (9%). Multivariate analysis identified higher amount of alcohol (however, in generally low‐dose procedures), higher baseline left ventricular ejection fraction and higher age as independent predictors of PG decrease ≥50%. Conclusions: The results of the first European multicenter and multinational study demonstrate that real‐world early outcomes of ASA patients are better than was reported in observations from the first decade after ASA introduction. © 2013 Wiley Periodicals, Inc.     

Low Incidence of Procedure-Related Major Adverse Cardiac Events After Alcohol Septal Ablation for Symptomatic Hypertrophic Obstructive Cardiomyopathy

Background

Alcohol septal ablation (ASA) is a catheter-based intervention that has been used as an alternative to surgical myectomy in highly symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). However, clinically relevant complications can result, including death and complete heart block (CHB) associated with syncope or resuscitation. This study was designed to evaluate the incidence of major ASA-related adverse cardiac events.

Methods

This international multicentre retrospective study included 421 patients in 8 European centres who were treated using ASA from April 1998 to January 2011. Clinical and echocardiographic follow-up (3-6 months) was completed in 394 patients (94%).

Results

ASA led to a significant reduction in symptoms and outflow gradients, with 0.7% mortality. A total of 70 patients (17%) experienced mostly transient CHB during and after the procedure; in 30% of them, CHB occurred or recurred later than 24 hours after ASA. Ninety-seven percent of CHB occurred up to the fifth day after ASA. Permanent pacemakers for CHB were implanted in 35 patients (8%). Multivariate analysis identified intraprocedural bundle branch block and age as independent predictors of CHB.

Conclusions

The results of the multicentre study demonstrate that ASA appears safe and efficacious, with low early mortality. The most frequent major complication after ASA was CHB (17%), which occurred late or was recurrent in almost one-third of these patients; 8% of patients required permanent pacemaker implantation. Independent predictors of CHB development were intraprocedural bundle branch block and age. Difficulty in predicting CHB should lead to close postprocedural monitoring and hospital stays lasting at least 5 days.     

Historical Milestones and Progress in the Research on Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy

The first alcohol septal ablation was performed almost 20 years ago in 1994; since then it has become a widely used technique for the treatment of highly symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). It has been shown that postprocedural basal septal shrinking as a result of myocardial scarring is followed by a decrease in left ventricular (LV) obstruction, regression of LV hypertrophy within the first postprocedural year, improvement of diastolic function, and reduction of the degree of mitral regurgitation. All these changes are accompanied by significant symptom relief. Although there is only limited evidence of postprocedural long-term survival, all the studies presented here are consistent in the low incidence of sudden death and similar prognoses with an age- and sex-matched general population. Conversely, we still have to be aware that a certain knowledge gap exists with regard to postprocedural long-term outcome. Therefore, careful selection of patients for alcohol septal ablation is needed, and all patients should be treated in centres offering all therapeutic options.     

梗阻性肥厚型心肌病经皮化学消蚀术后长期随访研究

目的　研究经皮化学消蚀术治疗梗阻性肥厚型心肌病的长期随访结果。方法　 13例不合并高血压的梗阻性肥厚型心肌病患者 ,左心室流出道压力阶差均 >40mmHg ,且长期药物治疗无效。其中 2例肥厚部位同时包括左心室侧壁和右心室。术后每月门诊记录临床症状变化及心电图 1次 ;术后 2 4h及每月行经胸超声检查 1次 ,测定室间隔厚度 (IVST)、心室腔直径 (LVDD)、左心室流出道压力阶差 (LVOTG)及左心室射血分数 (LVEF)。平均随访时间 2 0 (14～ 2 2 )个月。结果　 13例患者术前收缩期二尖瓣前向移动 (SAM)现象平均 3 6级 ;平均酒精注射量为 3 86ml;术后即刻左心室流出道压力阶差平均下降到 31mmHg ,术后 1个月室间隔厚度降低程度最大平均 (3 0± 0 4)mm ;术后 1个月时SAM分级平均下降到 1 4级 (平均下降 2 2级 ) ;无一例需要再次另外一支间隔支消蚀的 ;2例患者出现进行性左心室扩大 ,但是均于术后 3个月后停止 ;全部患者的临床症状均得到显著改善 ,1例患者于术后 3个月时出现活动后胸闷 ,心脏超声与导管复查左心室流出道压力阶差回升到 >36mmHg ;3例患者术中出现一过性完全性房室传导阻滞 ,2例术后 1h内恢复到正常窦性心律 ;1例完全性房室传导阻滞于术后第 3天消失 ,因此无 1例需要安装永久起搏器。 4例 (2 2 %     

Electrocardiographic changes after alcohol septal ablation in hypertrophic obstructive cardiomyopathy

Objective—To report acute and mid-term electrocardiographic changes in patients with hypertrophic obstructive cardiomyopathy (HOCM) after alcohol ablation of the first large septal branch of the left anterior descending coronary artery; and to relate electrocardiographic data with the left ventricular outflow tract pressure gradients.
Patients—Nine consecutive symptomatic patients with HOCM (mean (SD) age 45 (12) years).
Methods—Analysis of baseline and postprocedure ECGs and 24 hour ambulatory monitoring (up to six months). ECG data were related to left ventricular outflow tract pressure gradients.
Results—One patient developed complete atrioventricular block requiring permanent pacing. The PR interval was significantly prolonged up to third month after ablation. Immediately after the procedure all patients developed right bundle branch block. At the sixth month of follow up, right bundle branch block was present in four patients. New anterior ST elevation developed immediately after ablation in five of the nine patients, and new Q waves in four. The QRS duration was significantly prolonged immediately after ablation and during follow up. There was significant but transient prolongation of QT-mean and QTc-mean intervals. QT dispersion, QTc dispersion, and JTc-mean interval were not affected. JT and JTc dispersions were transiently prolonged. No serious ventricular arrhythmias were recorded during Holter monitoring, either before or after the procedure. There were no significant correlations between the left ventricular outflow tract pressure gradient and QTc, QT-d, QTc-d, JTc, JT-d, JTc-d, or QRS duration before and after ablation.
Conclusions—Alcohol septal ablation for HOCM induces significant changes in the resting ECG in most patients, despite the occlusion of a relatively small artery. The changes include new Q waves, new bundle branch block, transient anterior ST segment elevation, atrioventricular block, and transient prolongation of QT interval.

Keywords: hypertrophic obstructive cardiomyopathy;  alcohol septal ablation;  electrocardiography;  QT interval     

Percutaneous transluminal septal myocardial ablation for hypertrophic obstructive cardiomyopathy.

Percutaneous transluminal septal myocardial ablation (PTSMA) is a new therapeutic option for patients with hypertrophic obstructive cardiomyopathy (HOCM). In the present study, the acute and follow-up results of PTSMA were evaluated. From August 1997 to March 2003 27 medically refractory patients (New York Heart Association (NYHA) functional class 2.9+/-0.6) with HOCM underwent PTSMA. The target septal branch was determined by probationary ballooning in 3 and by myocardial contrast echocardiography in 24 patients. The mean resting left ventricular outflow tract pressure gradient (PG) was reduced from 70+/-44 to 24+/-22 mmHg (p<0.0001); the peak concentration of creatine kinase was 1545+/-686 IU/L. Although transient trifascicular block was observed in 14 patients, permanent pacemaker implantation was not required. There were no major adverse cardiac events during the hospital stay; the mean clinical follow-up was 2.2+/-1.7 years. Repeated PTSMA was needed in 1 patient; however, symptomatic improvement had been well preserved in all patients (NYHA class 1.2+/-0.4). Follow-up echocardiographic examination showed sustained improvement in PG, septal and left ventricular posterior wall thicknesses, and the grade of systolic anterior movement and regurgitation of the mitral valve. In conclusion, PTSMA is a safe and effective therapeutic option for medically refractory patients with HOCM.     

经皮经冠状动脉室间隔化学消融术治疗梗阻性肥厚型心肌病的近期疗效观察

目的评价经皮经冠状动脉室间隔化学消融术（PTSMA）治疗梗阻性肥厚型心肌病（HOCM）的近期疗效。方法自1998年8月～1999年11月收治HOCM34例,入选行PTSMA26例。利用Sigwart法行PTSMA,注入96%～99%无水酒精消融间隔支前后记录左室流出道压力阶差变化、心电图变化。在消融前及术后2周通过超声心动图测量室间隔（IVS）厚度及左室流出道宽度。结果术前平均静息左室流出道压力阶差为（72.8±24.6）mmHg（1mmHg=0.133kPa）,术中球囊加压后为（30.6±18.5）mmHg,术后为（24.3±17.6）mmHg,差异有显著性（P<0.001）。术前室间隔平均厚度为（23.00±6.03）mm,术后2周为（20.55±5.38）mm。术前左室流出道宽度为（6.54±2.36）mm,术后2周为（11.36±3.37）mm（P<0.01）。术前心功能（NYHA分级）为3.4±0.6,术后2周为1.6±0.8。术后CPK与CPK-Mb峰值分别为（1050±514）U/L与（131±78）U/L。术中及术后可见短阵室速、结性逸搏心律、三度房室传导阻滞及束支传导阻滞。1例发生永久性三度房室传导阻滞,安装永久性双腔起搏器。出现下壁及前壁心肌梗死心电图表现者各1例。结论PTSMA能显著降低左室流出道压力阶差,治疗HOCM的近期疗效可靠,但尚需进一步完善方法,以减少严重并发症发生,并需继续随访其中、远期疗效。     

Percutaneous Transluminal Septal Myocardial Ablation in Hypertrophic Obstructive Cardiomyopathy: Acute Results and 3-Month Follow-Up in 25 Patients

Objectives. We report the acute results and midterm clinical course after percutaneous transluminal septal myocardial ablation (PTSMA) in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM).Background. In the treatment of HOCM, surgical myectomy and DDD pacemaker therapy are considered the standard procedural extensions to drug therapy with negatively inotropic drugs. As an alternative nonsurgical procedure for reducing the left ventricular outflow tract (LVOT) gradient, PTSMA by alcohol-induced septal branch occlusion was introduced. However, clinical follow-up has not been sufficiently described.Methods. In 25 patients (13 women, 12 men; mean [±SD] age 54.7 ± 15.0 years) who were symptomatic despite sufficient drug therapy, 1.4 ± 0.6 septal branches were occluded with an injection of 4.1 ± 2.6 ml of alcohol (96%) to ablate the hypertrophied interventricular septum. After 3-months, follow-up results of LVOT gradients and clinical course were determined.Results. The invasively determined LVOT gradients could be reduced in 22 patients (88%), with a mean reduction from 61.8 ± 29.8 mm Hg (range 4 to 152) to 19.4 ± 20.8 mm Hg (range 0 to 74) at rest (p < 0.0001) and from 141.4 ± 45.3 mm Hg (range 76 to 240) to 61.1 ± 40.1 mm Hg (range 0 to 135) after extrasystole. All patients had angina pectoris for 24 h. The maximal creatine kinase increase was 780 ± 436 U/liter (range 305 to 1,810) after 11.1 ± 6.0 h (range 4 to 24). Thirteen patients (52%) developed a trifascicular block for 5 min to 8 days requiring temporary (n = 8 [32%]) or permanent (DDD) pacemaker implantation (n = 5 [20%]). An 86-year old woman died 8 days after successful intervention of uncontrollable ventricular fibrillation in conjunction with beta-sympathomimetics in chronically obstructive pulmonary disease. The remaining patients were discharged after 11.3 ± 5.4 days (range 5 to 24), after an uncomplicated hospital course. Clinical and echocardiographic follow-up was achieved in all 24 surviving patients after 3 months. No cardiac complications occurred. Twenty-one patients (88%) showed clinical improvement, with a New York Heart Association functional class of 1.4 ± 1.1. A further reduction in LVOT gradient was shown in 14 patients (58%).Conclusions. PTSMA of HOCM is a promising nonsurgical technique for septal myocardial reduction, with a consecutive reduction in LVOT gradient. Possible complications are trifascicular blocks, requiring permanent pacemaker implantation, and tachycardiac rhythm disturbances. Clinical long-term observations of larger patient series and a comparison with conventional forms of therapy are necessary to determine the conclusive therapeutic significance.     

Percutaneous transluminal septal myocardial ablation in drug-resistant hypertrophic obstructive cardiomyopathy: 18-month follow-up results.

OBJECTIVE: Surgery has been the only therapeutic option in patients with hypertrophic obstructive cardiomyopathy (HOCM) who are resistant to standard treatment. Percutaneous transluminal septal myocardial ablation (PTSMA) by alcohol-induced occlusion of the septal artery for the reduction of left ventricular outflow tract (LVOT) gradient is a novel method. However, long-term clinical follow-up is insufficient. This study reports the acute and mid-term results after PTSMA in symptomatic patients with HOCM. METHODS: Six patients (4 men and 2 women) with symptomatic HOCM and inadequate response to pharmacologic therapy had their major septal branches ablated with alcohol. Mean duration of follow-up was 1.5 years. RESULTS: There was reduction in LVOT gradient in all patients (100%) with a mean reduction of 50 mmHg. Two patients developed complete heart block (CHB) and 3 patients developed bifascicular block. CHB persisted in 1 patient. Two patients died within 8 days of the procedure; one due to cerebrovascular accident and 1 due to asystole. The patient who died of asystole had CHB but refused permanent pacemaker implantation. CHB reverted in 1 patient and bifascicular blocks persisted in 3 patients. Clinical and echocardiographic follow-up was achieved in the 4 surviving patients after 1.5 years. All surviving patients had LVOT gradient reduction and clinical improvement. CONCLUSION: PTSMA for HOCM is a non-surgical technique for reducing LVOT gradient. Heart blocks are one potential complication, and may require pacemaker implantation. Long-term follow-up and a larger series of patients are required to determine conclusive therapeutic significance.     

A novel approach in the use of radiofrequency catheter ablation of septal hypertrophy in hypertrophic obstructive cardiomyopathy

ObjectiveAlcohol septal ablation (ASA) is a therapeutic alternative to surgical myectomy in patients with hypertrophic obstructive cardiomyopathy (HOCM). However, the anatomical variability of the septal branch, risk of complete heart block, and late onset ventricular arrhythmias are limitations to its therapeutic usage. There is recent interest in the use of radiofrequency catheter ablation (RFCA) as a therapeutic option in HOCM. We aimed to assess the safety and efficacy of RFCA in the treatment of symptomatic HOCM.MethodsSeven patients with symptomatic HOCM (mean age 43.7 ± 15.6 years, five males), and significant left ventricular outflow tract (LVOT) gradient despite optimal drug therapy, underwent ablation of the hypertrophied interventricular septum. These patients had unfavorable anatomy for ASA. Ablation was performed under 3D electro-anatomical system guidance using an open irrigated tip catheter. The region of maximal LV septal bulge as seen on intracardiac echocardiography was targeted. Patients were followed up at 1, 6, and 12 months post-procedure.ResultsThe mean baseline LVOT gradient by Doppler echocardiography was 81 ± 14.8 mm of Hg which reduced to 48.5 ± 22.6 (p = 0.0004), 49.8 ± 19.3 (p = 0.0004), and 42.8 ± 26.1 mm of Hg (p = 0.05) at 1, 6, and 12 months respectively. Symptoms improved at least by one NYHA class in all but one patient. One patient developed transient pulmonary edema post-RFA. There were no other complications.ConclusionRFCA of the hypertrophied septum causes sustained reduction in the LVOT gradient and symptomatic improvement among patients with HOCM. Electroanatomical mapping helps to perform the procedure safely.     

Effect of biventricular pacing on left ventricular outflow tract pressure gradient in a patient with hypertrophic cardiomyopathy and normal interventricular conduction

We report a case of hypertrophic obstructive cardiomyopathy (HOCM) that was markedly improved by biventricular pacing. A 55-year-old woman with HOCM presented with palpitation and presyncope. Electrophysiologic study revealed an atrioventricular nodal reentrant tachycardia. After radiofrequency catheter ablation, a Mobitz type II atrioventricular block developed and a permanent pacemaker implantation was decided. Cardiac catheterization showed a left ventricular outflow tract (LVOT) gradient of 130 mmHg. Right dual-chamber and atrial-synchronous left ventricular epicardial pacing failed to reduce the gradient. After biventricular pacing, LVOT gradient decreased to 20 mmHg. Biventricular pacing may be an alternative therapy for patients with HOCM.     

60例梗阻性肥厚型心肌病化学消融治疗近期及中期疗效观察

目的探讨经皮室间隔心肌消融术(PTSMA)治疗梗阻性肥厚型心肌病(HOCM)方法及疗效.方法回顾分析采用心脏超声声学造影(MCE)介导下行PTSMA治疗的60例HOCM患者术后近期及中期的随访资料.结果60例患者中54例术后左室流出道压差(静息和激发)较术前下降》50%,6例下降》30%但《50%,PTSMA成功率100%;术后随访2周～6年,平均2.5年,56例患者临床症状明显改善或消失,3例症状复发,1例术后1年死于扩张型心肌病并发心力衰竭.无一例需安装永久心脏起搏器.结论PTSMA治疗HOCM近期及中期疗效显著、安全.     

Ablação septal alcoólica no tratamento da cardiomiopatia hipertrófica obstrutiva - experiência de quatro anos de um centro

IntroductionWe describe our center's initial experience with alcohol septal ablation (ASA) for the treatment of obstructive hypertrophic cardiomyopathy. The procedure, its indications, results and clinical outcomes will be addressed, as will its current position compared to surgical myectomy.ObjectiveTo assess the results of ASA in all patients treated in the first four years of activity at our center.MethodsWe retrospectively studied all consecutive and unselected patients treated by ASA between January 2009 and February 2013.ResultsIn the first four years of experience 40 patients were treated in our center. In three patients (7.5%) the intervention was repeated. Procedural success was 84%. Minor complications occurred in 7.5%. Two patients received a permanent pacemaker for atrioventricular block (6% of those without previous pacemaker). The major complication rate was 5%. There were no in-hospital deaths; during clinical follow-up (22±14 months) cardiovascular mortality was 2.5% and overall mortality was 5%.Discussion and ConclusionThe results presented reflect the initial experience of our center with ASA. The success rate was high and in line with published results, but with room to improve with better patient selection. ASA was shown to be safe, with a low complication rate and no procedure-related mortality. Our experience confirms ASA as a percutaneous alternative to myectomy for the treatment of symptomatic patients with obstructive hypertrophic cardiomyopathy refractory to medical treatment.     

经皮室间隔心肌消融术治疗老年肥厚型梗阻性心肌病的临床分析

目的　探讨经皮室间隔心肌消融术治疗老年肥厚型梗阻性心肌病 (HOCM)的可行性 ,安全性和近期效果。方法　对 6 0岁以上的 6例老年HOCM患者施行心肌声学造影指导下的经皮室间隔心肌消融术治疗。结果　 6例患者的经皮室间隔心肌消融术均获成功 ,未出现严重的心脏并发症 ,术后即刻应用心导管测左室流出道压差由术前(10 4.33± 19.6 1)mmHg降至 (35± 2 5 .88)mmHg(P <0 .0 0 1)。术后对 6例患者进行了 1～ 18个月的随访 ,经超声心动图测左室流出道压差由术前 (91.83± 2 7.17)mmHg降至 (36 .0 8± 33.6 3)mmHg(P <0 .0 5 ) ,室间隔厚度由术前(2 1.83± 2 .79)mm降至 (16 .0 2± 3.86 )mm (P <0 .0 5 )。术后心功能由术前的 3.4± 0 .5级改善为 1.1± 0 .3级 (P <0 .0 0 1)。结论　经皮室间隔心肌消融术治疗老年HOCM患者的即刻和近期效果良好 ,并发症少 ,安全性高。     

老年肥厚型梗阻性心肌病消融和起搏器治疗的对照观察

目的比较老年肥厚型梗阻性心肌病患者接受经冠状动脉消融肥厚心肌（TASH）或起搏器治疗的有效性和安全性。方法23例充分药物治疗不满意,心功能Ⅲ级（NYHA）以上的老年肥厚型梗阻性心肌病患者随机接受心肌声学造影指导下的TASH或根据血压优化PR间期的右心双腔起搏器治疗。其中2例接受TASH治疗者并发永久起搏器依赖而安装永久起搏器。对单纯接受TASH（13例）或起搏器（8例）治疗者进行了平均24个月的随访。结果接受两种治疗方法的患者心功能和主观症状积分均得到显著的改善。TASH组心功能由3．2±0．7级改善到1．5±0．5级,综合症状积分由5．9±1．6下降到1．8±0．7,P均〈0．001。起搏器治疗组心功能也由3．0±0．1改善到1．9±0．6级,综合症状积分也由4．5±1．3下降到2．3±1．6,P均〈0．01。综合症状改善程度TASH组明显优于起搏器治疗（4．2±1．5比2．3±1．3,P=0．007）。左心室流出道压力阶差TASH组平均下降了（79．9±35．5）mmHg（1mmHg=0．133kPa,P〈0．001）,起搏器治疗组平均下降了（49．3±37．7）mmHg（P〈0．05）,平均下降率分别为84％和53％。左心室流出道压力阶差下降率〉75％和〈50％TASH组分别有10例和1例,起搏器治疗组分别有4例和3例。TASH组治疗后室间隔厚度、左室舒张末径、收缩末径与术前比较变化显著[分别为（22．2±4．1）mm比（17．1±3．2）mm,（41．5±5．3）mm比（44．7±4．6）mm,（23．5±4．4）mm比（28．3±3．6）mm,P均〈0．05],但没有左室收缩功能异常。随访中,TASH组3例阵发性心房颤动中有2例转为慢性心房颤动,起搏器治疗组中2例阵发性心房颤动中1例发展成慢性心房颤动。结论TASH和起搏器治疗两种方法均能使老年肥厚型梗阻性心肌病患者心功能和综合症状得到显著改善,综合症状改善TASH优于起搏器治疗。TASH显著降低左心室流出道压力阶差,起搏器治疗中等程度降低心室流出道压力阶差。TASH导致的左心室流出道重构不会导致老年肥厚型梗阻性心肌病患者收缩功能的异常和左心室的扩张,但同样存在并发症,甚至严重并发症发生的可能。