Septal Reduction Therapy for Obstructive Hypertrophic Cardiomyopathy: Volume Still Matters for Septal Myectomy.

Abstract

HomeJournal of the American Heart AssociationVol. 12, No. 10Septal Reduction Therapy for Obstructive Hypertrophic Cardiomyopathy: Volume Still Matters for Septal Myectomy Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessEditorialPDF/EPUBSeptal Reduction Therapy for Obstructive Hypertrophic Cardiomyopathy: Volume Still Matters for Septal Myectomy Vincent Y. See and Libin Wang Vincent Y. SeeVincent Y. See https://orcid.org/0000-0001-6969-3827 , Hypertrophic Cardiomyopathy Center of Excellence, Division of Cardiovascular Medicine, Department of Medicine, , University of Maryland School of Medicine, University of Maryland Medical Center, , Baltimore, , MD, , USA, Search for more papers by this author and Libin WangLibin Wang *Correspondence to: Libin Wang, MD, PhD, Division of Cardiovascular Medicine, Department of Medicine, University of Maryland School of Medicine, 110 S. Paca St, Baltimore, MD 21201. Email: E-mail Address: [email protected] https://orcid.org/0009-0009-8843-7058 , Hypertrophic Cardiomyopathy Center of Excellence, Division of Cardiovascular Medicine, Department of Medicine, , University of Maryland School of Medicine, University of Maryland Medical Center, , Baltimore, , MD, , USA, Search for more papers by this author Originally published15 May 2023https://doi.org/10.1161/JAHA.123.030194Journal of the American Heart Association. 2023;12:e030194This article is a commentary on the followingHospital Procedural Volume and Clinical Outcomes Following Septal Reduction Therapy in Obstructive Hypertrophic CardiomyopathyOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 15, 2023: Ahead of Print Hypertrophic cardiomyopathy (HCM) is the most prevalent inherited cardiac disease affecting 1 in 200 to 500 people.1, 2, 3 About two‐thirds of patients with HCM have left ventricular outflow tract obstruction physiology who may carry worse outcome as compared with those with nonobstructive HCM.4In the era before the newly US Food and Drug Administration approved cardiac myosin ATPase inhibitor, mavacamten,5 physicians have relied upon beta‐blockers, nondihydropyridine calcium channel blockers, and the sodium channel blocker, disopyramide to decrease left ventricular outflow tract gradients aiming to relieve left ventricular outflow tract obstruction.6When medical therapy fails to reduce left ventricular outflow tract obstruction, there are 2 options for septal reduction therapy (SRT): septal myectomy (SM), which was developed in the 1960s7 and alcohol septal ablation (ASA), which was developed in the 1990s.8 Since the development of SRT, single‐center observational analyses from experienced centers have demonstrated high success rates of 90% to 95% and low surgical mortality risk of <1% for septal myectomy.9, 10, 11, 12 ASA also has low mortality risk, with prior concerns for late ventricular arrhythmias that have not been observed in more contemporary series.13However, by analyzing the National Inpatient Sample database for SM and ASA between 2003 and 2011, Kim and colleagues had noted that in‐hospital survival rates varied significantly between low‐ versus high‐volume surgical centers for SM and there was a strong inverse correlation between surgical volume and outcomes.14 During the same period of time, ASA outcomes were not dependent upon center volumes.14With an additional decade of experience, has the SRT inverse volume‐outcome relationship improved in the current era? In this issue of the Journal of the American Heart Association (JAHA), Altibi and colleagues analyzed SRT data from the National Readmission Databases during 2010 to 2019 with 19 007 encounters from 1701 hospitals across the United States.15 The inverse relationship between surgical volume and mortality for SM persisted, while mortality for ASA remained independent of volume.15The authors categorized SM volume as low (<8 procedures/year), medium (8–28 procedures/year), and high (>28 procedures/year) tertiles. ASA volume was defined as low (<7 procedures/year), medium (7–22 procedures/year), and high (>22 procedures/year) tertiles. They found that two‐thirds of the studied hospitals were low‐volume centers for both SM and ASA. The median volume for SM and ASA at low‐volume centers was 2 per year. The overall in‐hospital mortality post‐SM was 4.0% across the low‐, medium‐, and high‐volume centers. While this mainly came from 12% hospitals that performed 22.8% of the surgeries, there were 63 (3.7%) low‐volume hospitals with 100% in‐hospital mortality post‐SM. In‐hospital mortality was lower for isolated SM at 2.3%, as compared with SM cases with concomitant coronary artery bypass grafting, surgical aortic valve replacement, or mitral valve replacement at 6.2%.Overall, the low‐volume centers carried about 3 times higher in‐hospital mortality risk than the high‐volume centers (5.7% versus 3.9% versus 2.4% in low, medium, and high‐volume centers, respectively). Even after adjustment of patient and hospital baseline characteristics, the low‐volume centers still carried >2‐fold higher mortality risk for isolated SM than the high‐volume centers. Low SM volume was also associated with increased rates of acute kidney injury, complete heart block, pacemaker implant, mechanical circulatory support, and prolonged hospitalization. It is also noteworthy that the 63 low‐volume centers with 100% mortality rate had three quarters of their SM procedures conducted with coronary artery bypass grafting, surgical aortic valve replacement, or mitral valve replacement.While morbidity following SM was increased across all 3 tertiles, high‐volume centers had significantly lower inpatient mortality and readmission rates at both 30 and 90 days as compared with the low‐ and medium‐centers. Arrhythmia, conduction disorders, heart failure, pericardial disease, pulmonary issues, procedure complications, and septicemia were the most common 30‐day readmission reasons. High‐volume centers significantly outperformed low‐volume centers with regards to composite outcome of in‐hospital mortality, 30‐day mortality, and 30‐day readmission.On the other hand, ASA remains a low mortality risk procedure with only 3.6% centers that had >1% risk. In‐hospital mortality, adverse events, and readmission rate did not differ significantly among low‐, medium‐, and high‐volume hospitals.The data presented by Altibi and colleagues reconfirm the inverse volume‐mortality relationship for SM in current practice. These data are particularly timely as we enter a new era of medical treatment for obstructive HCM.5 Mavacamten has been shown to significantly reduce short‐term SRT requirement while long‐term efficacy is under active investigation.16 While the scope of HCM medical therapies broadens, this work re‐emphasizes the recommendations from the 2020 American Heart Association/American College of Cardiology Guideline for the Diagnosis and Treatment of Patients with Hypertrophic Cardiomyopathy,12 that patients with obstructive HCM who are candidates for SRT should be referred to comprehensive HCM centers, especially for septal myectomy, to improve patient outcomes.DisclosuresNone.Footnotes*Correspondence to: Libin Wang, MD, PhD, Division of Cardiovascular Medicine, Department of Medicine, University of Maryland School of Medicine, 110 S. Paca St, Baltimore, MD 21201. Email: [email protected]umaryland.eduThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.This manuscript was sent to Ferhaan Ahmad, MD, PhD, Senior Associate Editor, for editorial decision and final disposition.For Disclosures, see page 2.See Article by Altibi et al.References1 Maron BJ, Gardin JM, Flack JM, Gidding SS, Kurosaki TT, Bild DE. Prevalence of hypertrophic cardiomyopathy in a general population of young adults. Echocardiographic analysis of 4111 subjects in the CARDIA study. Coronary Artery Risk Development in (Young) Adults. Circulation. 1995; 92:785–789. doi: 10.1161/01.cir.92.4.785LinkGoogle Scholar2 Wang L, Seidman JG, Seidman CE. Narrative review: harnessing molecular genetics for the diagnosis and management of hypertrophic cardiomyopathy. Ann Intern Med. 2010; 152:513–520. doi: 10.7326/0003-4819-152-8-201004200-00008CrossrefMedlineGoogle Scholar3 Semsarian C, Ingles J, Maron MS, Maron BJ. 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J Am Coll Cardiol. 2022; 80:95–108. doi: 10.1016/j.jacc.2022.04.048CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. 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Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.https://doi.org/10.1161/JAHA.123.030194PMID: 37183877 Originally publishedMay 15, 2023 Keywordsalcohol septal ablationseptal myectomyEditorialsobstructive hypertrophic cardiomyopathyseptal reduction therapyPDF download SubjectsCardiomyopathyCardiovascular SurgeryCatheter-Based Coronary and Valvular InterventionsMortality/Survival