Alcohol Septal Ablation in Young HCM Patients
Is alcohol septal ablation (ASA) safe and effective among younger patients with obstructive hypertrophic cardiomyopathy (HCM)?
A total of 1,197 patients with obstructive HCM who underwent ASA at seven different centers in Europe between 1996 and 2015 were evaluated. Patients were divided into three age groups: young (≤50 years; middle-age [51-64 years]; older [≥65 years]), and outcomes were compared between age groups. Primary endpoints were long-term all-cause mortality and adverse events including sudden cardiac death, resuscitated cardiac arrest, and appropriate implantable cardioverter-defibrillator (ICD) shock. Secondary endpoints included periprocedural atrioventricular block, cardiac tamponade, pacemaker implantation, persistent provocable gradient, and need for reintervention within 30 days.
During a mean follow-up period of 5.4 ± 4.2 years, mortality rates were 1% per year in young, 2% per year in middle-aged, and 5% per year in older patients. Follow-up was complete for 99.6% of the cohort. Younger patients had high rates of symptom alleviation (95% New York Heart Association class I or II), similar rates of adverse events (0.8%/year), very low 30-day mortality (0.3%), and significantly lower risk of permanent pacemaker implantation compared with older patients. Use of <2.5 ml of alcohol was associated with better survival rates in young patients.
The authors concluded that ASA for obstructive HCM is safe in younger patients and is associated with effective long-term symptom relief.
This report from a large registry of patients with obstructive HCM treated with ASA supports the long-term safety and efficacy of ASA in younger patients when ASA was performed at an experienced center. The 2011 American College of Cardiology Foundation/American Heart Association guidelines on HCM recommend surgical myectomy (Class IIa) over ASA (Class IIb) in patients who are candidates for both therapies. Risks of ASA include high rates of atrioventricular block and persistent left ventricular outflow tract gradients. Based on data from the current study, there was effective symptom control in younger patients over long-term follow-up. However, one third developed complete heart block and 8% required a permanent pacemaker. In addition, a large quantity of patients required repeat ASA (67-82%) in the entire cohort. In the absence of randomized controlled trials comparing surgical myectomy and ASA, based on the results of this analysis, treatment decisions should weigh the risks and benefits of both treatment options regardless of age.
Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Pericardial Disease, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure
Keywords: Ablation Techniques, Arrhythmias, Cardiac, Atrioventricular Block, Cardiac Tamponade, Cardiomyopathy, Hypertrophic, Death, Sudden, Cardiac, Defibrillators, Implantable, Ethanol, Heart Failure, Pacemaker, Artificial, Risk Assessment, Survival Rate
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