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Long-Term Outcomes in High-Risk Symptomatic Patients With Hypertrophic Cardiomyopathy Undergoing Alcohol Septal Ablation

Deborah H. Kwon, MD^_*, Samir R. Kapadia, MD, FACC^_*, E. Murat Tuzcu, MD, FACC^_*, Carmel M. Halley, MD^_*, Eiran Z. Gorodeski, MD, MPH^_*, Ronan J. Curtin, MD^_*, Maran Thamilarasan, MD, FACC^_*, Nicholas G. Smedira, MD, FACC, Bruce W. Lytle, MD, FACC, Harry M. Lever, MD, FACC^_*, Milind Y. Desai, MD, FACC^_*,_*

^_* Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
Department of Cardiothoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.

^_* Reprint requests and correspondence: Dr. Milind Y. Desai, Department of Cardiovascular Medicine, Desk F 15, 9500 Euclid Avenue, Cleveland, Ohio 44195. (Email: desaim2{at}ccf.org).

Objectives: We sought to assess outcomes of alcohol septal ablation (ASA) in high-risk patients.

Background: Because surgical myectomy is the preferred treatment in patients with symptomatic hypertrophic obstructive cardiomyopathy (HOCM) at our institution, we perform ASA in patients who are at high risk for surgery.

Methods: We studied 55 symptomatic HOCM patients (mean age 63 ± 13 years, 67% women, mean follow-up 8 ± 1 years), at high risk for surgery (as the result of age/comorbidities) who had ASA between 1997 and 2000. The following were recorded at baseline, 3 months, and 1 year: septal thickness, maximal (resting or provocable) left ventricular outflow tract gradient, Minnesota living with heart failure questionnaire score, and the presence of a permanent pacemaker. All-cause mortality was recorded.

Results: No patients died at 48 h, 2 died at 1 year, 7 died at 5 years, and 13 died at 10 years. Only age >65 years at time of ASA predicted long-term mortality (log-rank p = 0.03). Mean maximal left ventricular outflow tract gradient (104 ± 35 mm Hg vs. 49 ± 28 mm Hg), septal thickness (2.4 ± 0.4 cm vs. 1.8 ± 0.6 cm), and Minnesota living with heart failure score (63 vs. 25) improved at 3 months, compared with baseline (all p < 0.001), with no significant changes at 1 year. New permanent pacemaker was present in 26% of patients.

Conclusions: In symptomatic HOCM patients who are at high risk for surgery, ASA is associated with symptomatic improvement and low short-term mortality; with long-term mortality only associated with older age at time of procedure. In symptomatic HOCM patients at high-risk for surgery, ASA is a viable option.

Key Words: hypertrophic cardiomyopathy • percutaneous alcohol septal ablation • long-term outcomes

Abbreviations and Acronyms   AICD = automatic implantable cardioverter defibrillator   ASA = alcohol septal ablation   HOCM = hypertrophic obstructive cardiomyopathy   LVOT = left ventricular outflow tract   MLWHF = Minnesota Living With Heart Failure   MR = mitral regurgitation   NYHA = New York Heart Association   PPM = permanent pacemaker   SSDI = Social Security Death Index   VT = ventricular tachycardia