Prognostic impact of baseline septal thickness and ethanol dose during long-term followup percutaneous septal ablation

Transcription

1 Prognostic impact of baseline septal thickness and ethanol dose during long-term followup percutaneous septal ablation Christian Prinz¹, Detlef Hering¹, Olaf Oldenburg¹, Dieter Horstkotte¹, Lothar Faber¹ ¹Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany ESC Congress, 2010, Stockholm

2 Introduction - Hypertrophic obstructive cardiomyopathy (HOCM) is defined as a primary, frequently familial and genetically determined condition characterized by myocardial hypertrophy and dynamic left ventricular outflow tract (LVOT) obstruction [1, 2]. - Medical therapy with negative inotropic drugs is the first line of treatment in order to reduce symptoms and to improve functional capacity. - Surgical myectomy has traditionally been the treatment of choice for patients with drug-refractory symptoms and LVOT obstruction [3-5]. [1] Wigle et al., Circulation 1995; 92: [2] Maron et al., J Am Coll Cardiol 2003; 42: [3] Schoendube et al., Circulation 1995; 92: II [4] Schulte et al., Schweiz Med Wchenschr 1995; 125: [5] Heric et al., J Thorac Cardiovasc Surg 1995; 110:

3 Introduction Echocardiography of a patient with extreme left ventricular hypertrophy

4 Introduction - Sudden cardiac death (SCD) is probably the most devastating complication of HCM, especially in young people without severe symptoms [1] - The overall annual mortality rate of HCM is about 1 % [2], with probably much higher risk in small subsets [1] Maron et al., N Engl J Med 2003; 349: [2] Maron et al., Circulation 2000; 102:

5 Introduction Risk assessment in HCM patients [1] Secondary prophylaxis: Prior cardiac arrest or spontaneous sustained ventricular tachycardia Primary prophylaxis: 1. Positive family history for HCM-related death 2. Syncope, particularly exertional or recurrent 3. Hypotensive blood pressure response to exercise 4. Extreme LVH with maximum wall thickness of 30 mm or more 5. nsvt on Holter ECG [1] Elliott et al., J Am Coll Cardiol 2000; 36:

6 Introduction ACC/ESC-Guidelines (Eur. Heart J. 2003)

7 Introduction Echo-guided percutaneous septal ablation (PTSMA,TASH, ASA, ESA) [1, 2] - Hemodynamic measurements to evaluate the severity of LVOT obstruction - The target vessel (one of the proximal septal perforator arteries) is selected after assessment of coronary morphology - The target vessel is selectively engaged with a short over-the-wire balloon ( mm) - Reflux is excluded angiographically and intra-procedural tranthoracic echocardiography is performed - Alcohol is injected slowly under permanent fluoroscopic control (1.0 ml/cm of septum) - After injection, the balloon remaines inflated for an additional 10 min to enhance tissue contact and to exclude any spillover of alcohol into the vessel from which the septal perforator originates - Repeat hemodynamic measurements and a new angiography to exclude a damage to the left coronary tree [1] Sigwart, Lancet 1995; 346: [2] Faber et al., Circulation 1998; 98:

8 Introduction Intraprocedural echo monitoring for target vessel selection in PTSMA.

9 Introduction Maron JAMA 2007

10 Introduction Aim of the study To define risk markers for long-term mortality after percutaneous septal ablation (PTSMA) for patients with symptomatic obstructive hypertrophic cardiomyopathy (HOCM)

11 Methods We analyzed the long-term outcome of 373 consecutive patients treated with PTSMA between 1996 and Data were acquired by outpatient examination in our own institution or by phone contact with the patients local cardiologists.

12 Results Early results Adabaq JACC (during 2008in-hospital stay following PTSMA) Mean age at PTSMA [years] 54 ± 14 In-hospital mortality [pts] 5 (1 %) CK-rise [U/l, reference:<80] 517 ± 256 Alcohol dose [ml] 2.6 ± 1.1 [1-4ml] Pacemaker implantation [pts] 25 (7 %)

13 Results Two patients with HOCM (a, c) b 4 months after myectomy d 4 months after PTSMA

14 Results Number of patients Follow-up results after PTSMA (79±40 months) Affected patients Non- Affected patients 1: death 3: non-cardiovascular death 5: Re-PTSMA 2: cardiovascular death 4: Re-intervention 6: Myectomy post PTSMA

15 Results Survival was 92 % at 5 years, and 90 % at 10 years. 21% NYHA III NYHA classification at last follow-up 79% NYHA II

16 Results Risk markers Pts with death during follow-up Pts still alive p Left atrium [mm] at follow-up 50 ± 9 46 ± IVS at baseline [mm] 23 ± 4 20 ± Ethanol dose [ml] 3.2 ± ± Max. wall thickness >30 mm at baseline [Pts] VT on Holter ECG at baseline [Pts] 7 (27 %) 26 (8 %) (39 %) 66 (19 %) Positive family history for SCD Inadequate BPR Syncope n.s. n.s. n.s.

17 Conclusion 1. During long-term follow-up after PTSMA, a persistent clinical improvement was observed. 2. A total mortality rate of 1.5 %/pt.-year, including all procedure-related deaths, compares favourably with the natural course of this patient group. 3. Ethanol dose, degree of LV thickening, LA dilatation, and occurence of VT seem to indicate a higher risk after PTSMA.

18 Thank you for your attention!