Abstract
Surgical myectomy (SM) and alcohol septal ablation (ASA) are two invasive therapies for symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM), despite medical therapy. This meta-analysis aims to compare the efficacy of the two procedures. We searched all electronic databases until February 2020 for clinical trials and cohorts comparing clinical outcomes of ASA and SM treatment of patients with HOCM. The primary endpoint was all-cause mortality, cardiovascular (CV) mortality, sudden cardiac death (SCD), re-intervention, and complications. Secondary endpoints included relief of clinical symptoms and drop of left ventricular outflow tract (LVOT) gradient. Twenty studies (4547 patients; 2 CTs and 18 cohorts) comparing ASA vs. SM with a mean follow-up of 47 ± 28.7 months were included. Long term (8.72 vs. 7.84%, p = 0.42) and short term (1.12 vs. 1.27%, p = 0.93) all-cause mortality, CV mortality (2.48 vs. 3.66%, p = 0.26), SCD (1.78 vs. 0.76%, p = 0.20) and stroke (0.36 vs. 1.01%, p = 0.64) were not different between procedures. ASA was associated with lower peri-procedural complications (5.57 vs. 10.5%, p = 0.04) but higher rate of re-interventions (10.1 vs. 0.27%; p < 0.001) and pacemaker dependency (12.4 vs. 4.31%, p = 0.0004) compared to SM. ASA resulted in less reduction in LVOT gradient (−47.8 vs. −58.4 mmHg, p = 0.01) and less improvement of clinical symptoms compared to SM (New York Heart Association (NYHA) class III/IV, 82.4 vs. 94.5%, p < 0.001, angina 53.2 vs. 84.2%, p = 0.02). Thus, ASA and SM treatment of HOCM carry a similar risk of mortality. Peri-procedural complications are less in alcohol ablation but re-intervention and pacemaker implantations are more common. These results might impact the procedure choice in individual patients, for the best clinical outcome.
Highlights
Hypertrophic cardiomyopathy (HCM) is the most common inheritable heart disease characterized by left ventricular (LV) hypertrophy, diverse clinical presentation and hemodynamic abnormalities [1]
Additional searches for potential trials included the references of review articles on the subject, and the abstracts from the following congresses: scientific sessions of the European Society of Cardiology (ESC), the American Heart Association (AHA), American College of Cardiology (ACC), and European Association of Cardiovascular Imaging (EACVI)
During follow-up, alcohol septal ablation (ASA) resulted in a lower reduction in left ventricular outflow tract (LVOT) gradient (−47.8 vs. −58.4 mmHg, p = 0.01, Figure 5) and less improvement of clinical symptoms compared to septal myectomy (SM): angina 53.2 vs. 84.2%, p = 0.02 and New York Heart Association (NYHA) class III/IV, 82.4 vs. 94.5%, p < 0.001, (Figure 6a,b and Figure S4) despite a similar reduction in IVSd (−4.07 vs. −4.50 mm, p = 0.10), similar increase in LVEDD and similar reduction in EF (p = 0.32 and p = 0.83, respectively) (Figures S5a,b and S6a)
Summary
Hypertrophic cardiomyopathy (HCM) is the most common inheritable heart disease characterized by left ventricular (LV) hypertrophy, diverse clinical presentation and hemodynamic abnormalities [1]. Left ventricular outflow tract obstruction (LVOTO) is a characteristic feature of many patients with HCM [2]. To control symptoms in those patients with hypertrophic obstructive cardiomyopathy (HOCM) when medical therapies fail, septal myectomy (SM) and alcohol septal ablation (ASA), are two invasive treatments that are used, but with no consensus. Despite many studies comparing the outcome of the two treatment strategies, debates on the effectiveness of the two methods [9,10,11] still exist, which make the best treatment choice difficult at times The aim of this meta-analysis is to compare the efficacy of the two treatment procedures on short and long-term clinical outcomes
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