Nonsurgical Septal Reduction Therapy Research Articles

Non-surgical septal reduction therapy in hypertrophic cardiomyopathy

### Learning objectives Hypertrophic cardiomyopathy (HCM) is an inherited disease characterised by otherwise unexplained hypertrophy of the myocardium. It is transmitted in an autosomal dominant pattern with variable penetrance, with...

Current status of nonsurgical septal reduction therapy in hypertrophic obstructive cardiomyopathy

Nonsurgical septal reduction therapy for hypertrophic obstructive cardiomyopathy patients has been available since 1994. Medium-term case series following alcohol septal ablation (ASA) are now available. Procedural risk is low and a significant improvement in symptom burden and left ventricular outflow tract gradient is observed in most cases. Success to medium-term is comparable to surgical septal myectomy. Increased risk of ventricular arrhythmia and sudden cardiac death has not been satisfactorily demonstrated post-ASA. Some series suggest improved survival following removal of the outflow tract gradient with ASA. Limited progress has been made in developing techniques in ASA since the introduction of myocardial contrast echocardiography. Refinements may be possible through improved guidance and imaging, but the need for alternative forms of nonsurgical septal reduction therapy is highlighted by technical and vascular limitations.

Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy: A Systematic Review of Published Studies

Alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM) has emerged as a lesser invasive alternative to surgical myectomy over the past decade. The purpose of this study is to analyze all the published literature on outcomes and complications after ASA. MEDLINE and PubMed were searched for all available published literature on ASA (June 1996-June 2005) using the terms hypertrophic obstructive cardiomyopathy (HOCM), alcohol septal ablation for hypertrophic obstructive cardiomyopathy, alcohol septal ablation for HOCM, alcohol septal ablation (ASA), transcoronary alcohol septal ablation for hypertrophic obstructive cardiomyopathy (TASH), transcoronary alcohol septal ablation for HOCM, nonsurgical septal reduction therapy (NSRT), and percutaneous transcoronary septal myocardial ablation (PTSMA). A total of 42 published studies (2,959 patients) were analyzed. Mean age was 53.5 (35.4-72) years with a mean male to female ratio of 1.17. Mean follow-up was 12.7 +/- 0.3 months (1.5-43.2). Absolute ethanol (3 mL) was injected in 1.2 septal perforator arteries. On average, serum CK peaked at 964 units. At 12 months, there was a sustained decrease in resting and provoked LVOT gradient (65.3-15.8 and 125.4-31.5 mmHg, respectively) accompanied by reduction in basal septal diameter (20.9-13.9 mm), improvement in NYHA Class (2.9-1.2), and increase in exercise capacity (325.3-437.5 seconds). Early mortality (within 30 days) was 1.5% (0.0-5.0%) and late mortality (beyond 30 days) was 0.5% (0.0-9.3%). Other complications include ventricular fibrillation (2.2%), LAD dissection (1.8%), complete heart block requiring permanent pacemaker (10.5%), and pericardial effusion (0.6%). A repeat ASA was performed on 6.6% of patients and 1.9% of patients underwent surgical myomectomy with resolution of symptoms. Literature to date suggests that ASA results in acute and intermediate-term favorable clinical and echocardiographic outcomes. A randomized controlled trial is needed to compare ASA and myomectomy in order to determine which technique provides maximal benefit.

Impact of infarct size on clinical and echocardiographic outcome in patients undergoing nonsurgical septal reduction therapy

Abstract Background Nonsurgical septal reduction therapy (NSRT) with ethanol improves clinical and hemodynamic parameters in patients with symptomatic hypertrophic obstructive cardiomyopathy. The purpose of this study was to examine the impact of infarct size induced by ethanol injection on clinical and echocardiographic outcome after the procedure. Methods and results The first 261 consecutive patients were included. The mean age was 51 ± 6 years, and 127 patients were women. The mean creatine kinase (CK) after NSRT was 1411 ± 653 units. Men had larger infarcts than women ( P = .0028). Injecting ethanol as a bolus ( P 1 septal branch ( P 3 cc of ethanol per septal branch ( P 1000 U/dL compared to those with peak CK 1500 U/dL had a significant drop in left ventricular ejection fraction at 6 weeks (70 ± 6 vs 63 ± 6, P = .035). Conclusion An average size infarct (peak CK 1000–1500 U/dL) seems to lead to the optimal outcome after NSRT.

February 10, 2004

HomeCirculationVol. 109, No. 5February 10, 2004 Free AccessAnnouncementPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessAnnouncementPDF/EPUBFebruary 10, 2004 James T. Willerson, MD James T. WillersonJames T. Willerson Search for more papers by this author Originally published10 Feb 2004https://doi.org/10.1161/circ.109.5.557Circulation. 2004;109:557Editor’s Comments for the Current Issue of CirculationCirculation. 2004;109:557–693We have devoted much of the current issue of Circulation to the problems of cardiovascular disease in women. The cover figure, three Focused Perspectives, the Clinician Update, eight of the Clinical Investigation and Reports papers, and the AHA Scientific Statement address problems of clinicial relevance to women’s cardiovascular health. We hope the issue will be useful to our readers.CIRCULATION’S NEWEST FEATURE!!!ONLINE SUBMISSION AND PEER REVIEW IS NOW AVAILABLEhttp://circ.ahajournals.orgORhttp://submit-circ.ahajournals.orgWill take you there.…Cardiovascular NewsImages in Cardiovascular MedicineAvoiding Papillary Muscle Infarction With Myocardial Contrast Echocardiographic Guidance of Nonsurgical Septal Reduction Therapy for Hypertrophic Obstructive CardiomyopathySherif F. Nagueh, MD; Nasser M. Lakkis, MD; Katherine J. Middleton, RCT; Jennifer Franklin, RN; William H. Spencer III, MD (Circulation. 2004; 109:e27–e28Google Scholar.) Correspondence (Circulation. 2004; 109:e29–e37Google Scholar.) Previous Back to top Next FiguresReferencesRelatedDetails February 10, 2004Vol 109, Issue 5 Advertisement Article InformationMetrics https://doi.org/10.1161/circ.109.5.557 Originally publishedFebruary 10, 2004 PDF download Advertisement

Images in cardiovascular medicine. Avoiding papillary muscle infarction with myocardial contrast echocardiographic guidance of nonsurgical septal reduction therapy for hypertrophic obstructive cardiomyopathy.

Intracoronary myocardial contrast echocardiography (MCE) can be used to guide the delivery of ethanol during nonsurgical septal reduction therapy for hypertrophic obstructive cardiomyopathy. The echocardiographic contrast agent is injected immediately before the injection of ethanol, down the lumen of the inflated balloon that resides in the target septal coronary artery. This is the artery that supplies the area of the septum involved with the mitral leaflet(s) in causing dynamic outflow tract obstruction. MCE provides a direct visualization of the myocardial territory that should receive ethanol and consequently undergo infarction. In rare instances, the cannulated vessel does not supply the culprit septal segment(s) but supplies instead …

Impact of infarct size on clinical and echocardiographic outcome in patients undergoing nonsurgical septal reduction therapy

Background Nonsurgical septal reduction therapy (NSRT) with ethanol improves clinical and hemodynamic parameters in patients with symptomatic hypertrophic obstructive cardiomyopathy. The purpose of this study was to examine the impact of infarct size induced by ethanol injection on clinical and echocardiographic outcome after the procedure. Methods and results The first 261 consecutive patients were included. The mean age was 51 ± 6 years, and 127 patients were women. The mean creatine kinase (CK) after NSRT was 1411 ± 653 units. Men had larger infarcts than women ( P = .0028). Injecting ethanol as a bolus ( P < .001), injecting >1 septal branch ( P < .001), or injecting >3 cc of ethanol per septal branch ( P < .001) were all determinants of infarct size. When the patients were divided into 4 groups according to peak CK, the New York Heart Association dyspnea score after NRST, the septal thickness, and left ventricular outflow tract gradient were more significantly reduced in patients with peak CK >1000 U/dL compared to those with peak CK <1000 U/dL. Patients with peak CK >1500 U/dL had a significant drop in left ventricular ejection fraction at 6 weeks (70 ± 6 vs 63 ± 6, P = .035). Conclusion An average size infarct (peak CK 1000–1500 U/dL) seems to lead to the optimal outcome after NSRT.

Complete heart block: determinants and clinical impact in patients with hypertrophic obstructive cardiomyopathy undergoing nonsurgical septal reduction therapy

Complete heart block: determinants and clinical impact in patients with hypertrophic obstructive cardiomyopathy undergoing nonsurgical septal reduction therapy

Complete heart block: determinants and clinical impact in patients with hypertrophic obstructive cardiomyopathy undergoing nonsurgical septal reduction therapy

ObjectivesThe purpose of this paper is to examine the incidence and determinants of permanent complete heart block (CHB) after nonsurgical septal reduction therapy (NSRT), and to evaluate the clinical impact of permanent pacemaker (PPM) placement. BackgroundNonsurgical septal reduction therapy with ethanol improves the clinical and hemodynamic parameters in patients with symptomatic hypertrophic obstructive cardiomyopathy. Complete heart block is a common complication after NSRT. MethodsThe database of 261 consecutive patients who underwent NSRT at Baylor College of Medicine was reviewed. Clinical variables that were considered as possible determinants for CHB after NSRT were: age, gender, New York Heart Association (NYHA) functional class, left ventricular outflow tract (LVOT) gradient at rest or with provocation, septal thickness, and baseline exercise duration. For electrocardiographic (ECG) variables, the presence of first-degree atrioventricular (AV) block, bifascicular block, left bundle branch block, atrial fibrillation, and left ventricular hypertrophy were analyzed. In addition, the volume of ethanol injected, the method of administration of ethanol (i.e., bolus vs. slow injection [over 30 to 60 s]), number of septal arteries occluded, use of myocardial echocardiography, and infarct size as determined by peak creatine kinase level. ResultsOf 261 consecutive patients, 37 had PPM or automatic implantable cardiac defibrillator placed before NSRT. Of the remaining 224 patients, 31 (14%) developed CHB after the procedure. Multivariate logistic regression analysis showed that female gender (odds ratio [OR] 4.3; p = 0.02), bolus injection of ethanol (OR 51; p = 0.004), injecting more than one septal artery (OR 4.6; p = 0.016), the presence of left bundle branch block (OR 39; p = 0.002), and first-degree AV block (OR 14; p = 0.001) on the baseline ECG are independent predictors of CHB after NSRT. Patients requiring PPM placement had a similar improvement in their NYHA functional class, septal thickness reduction, LVOT gradient reduction, and improvement of exercise capacity when compared with patients who did not require pacing. ConclusionsMultiple demographic, electrocardiographic, and technical factors seem to increase the risk of CHB after NSRT. Patients with CHB after NSRT derive similar clinical and hemodynamic benefit to patients who did not require permanent pacing.

Role of controlled septal infarct in hypertrophic obstructive cardiomyopathy.

Hypertrophic obstructive cardiomyopathy is a complex and challenging disease. Medical therapy, surgical therapy, and pacing therapy have been used with some success over the years. Nonsurgical septal reduction therapy, also called alcohol septal ablation, has been used recently as a percutaneous catheter-based intervention to improve left ventricular outflow tract obstruction and thereby improve symptoms. The reported results of this procedure have shown impressive reductions in gradient and improvement in symptoms at relatively low risk. The most common complication of the procedure, development of complete heart block requiring a permanent pacemaker, has improved in recent studies with refinements of the procedural technique. Nonsurgical septal reduction therapy has been shown to improve diastolic function, decrease left ventricular hypertrophy and mass, and cause changes at the cellular and molecular level that improve myocardial function. Reported results at 1 year follow-up continue to show benefit, and long-term studies are ongoing.

Comparison of ethanol septal reduction therapy with surgical myectomy for the treatment of hypertrophic obstructive cardiomyopathy

OBJECTIVESThis study was designed to compare the hemodynamic efficacy of nonsurgical septal reduction therapy (NSRT) by intracoronary ethanol with standard therapy (surgical myectomy) for the treatment of hypertrophic obstructive cardiomyopathy (HOCM).BACKGROUNDNonsurgical septal reduction therapy has gained interest as a new treatment modality for patients with drug-refractory symptoms of HOCM; however, its benefits in comparison to surgery are unknown.METHODSForty-one consecutive NSRT patients at Baylor College of Medicine with one-year follow-up were compared with age- and gradient-matched septal myectomy patients at the Mayo Clinic. All patients had left ventricular outflow obstruction with a resting gradient ≥40 mm Hg and none had concomitant procedures.RESULTSThere were no baseline differences in New York Heart Association class, severity of mitral regurgitation, use of cardiac medications or exercise capacity. One death occurred during NSRT because of dissection of the left anterior descending artery. At one year, all improvements in both groups were similar. After surgical myectomy, more patients were on medications (p < 0.05) and there was a higher incidence of mild aortic regurgitation (p < 0.05). After NSRT, the incidence of pacemaker implantation for complete heart block was higher (22% vs. 2% in surgery; p = 0.02). However, seven of the nine pacemakers in the NSRT group were implanted before a modified ethanol injection technique and the use of contrast echocardiography.CONCLUSIONSNonsurgical septal reduction therapy resulted in a significantly higher incidence of complete heart block, but the risk was reduced with contrast echocardiography and slow ethanol injection. Surgical myectomy resulted in a significantly higher incidence of mild aortic regurgitation. Nonsurgical septal reduction therapy, guided by contrast echocardiography, is an effective procedure for treating patients with HOCM. The hemodynamic and functional improvements at one year are similar to those of surgical myectomy.

Regression of left ventricular hypertrophy after nonsurgical septal reduction therapy of hyperthrophic obstructive cardiomyopathy

Regression of left ventricular hypertrophy after nonsurgical septal reduction therapy of hyperthrophic obstructive cardiomyopathy

Efficacy of nonsurgical septal reduction therapy in symptomatic patients with obstructive hypertrophic cardiomyopathy and provocable gradients

The hemodynamic burden caused by left ventricular obstruction along with impaired systolic and diastolic function explains the disabling symptoms of heart failure that are common in patients with obstructive hypertrophic cardiomyopathy (HC). 1 Relief of the outflow obstruction is the cornerstone of the successful treatment of this disease. 2 Medical therapy with negative inotropic medications like b blockers, calcium antagonists, and disopyramide are the first line of treatment. 3,4 Many patients, however, continue to experience symptoms despite optimal medical therapy. These patients are left with 3 options: myotomymyomectomy, 5‐7 dual-chamber pacing, 8 ‐12 or nonsurgical septal reduction. 13‐20 In this report, we share our experience with nonsurgical septal reduction in symptomatic patients with low resting gradients (,30 mm Hg), and significant (.60 mm Hg) provocable gradients after the infusion of low-dose dobutamine. ••• All patients were evaluated before the procedure by 1 of the primary investigators to verify their symptoms and diagnosis. Only patients with severe, drugresistant symptoms of dyspnea (New York Heart Association [NYHA] class III or IV), angina (Canadian Cardiovascular Society class III or IV), or syncope were accepted for therapy. All patients underwent echocardiographic evaluation with Doppler studies. All enrolled patients had a septal to posterior wall thickness wall ratio of $1.3. Patients with symptoms and a low resting gradient were provoked with a mean dose of 10.0 mg/kg/min of dobutamine; the same dose was used at follow-up. Patients were considered candidates for this treatment if their dobutamine-provoked gradient was .60 mm Hg. Informed consent, as approved by the Institutional

Echocardiographic insights into the mechanisms of relief of left ventricular outflow tract obstruction after nonsurgical septal reduction therapy in patients with hypertrophic obstructive cardiomyopathy

Echocardiographic insights into the mechanisms of relief of left ventricular outflow tract obstruction after nonsurgical septal reduction therapy in patients with hypertrophic obstructive cardiomyopathy

Regression of left ventricular hypertrophy after nonsurgical septal reduction therapy for hypertrophic obstructive cardiomyopathy.

Hypertrophic obstructive cardiomyopathy (HOCM) is characterized by left ventricular hypertrophy (LVH) in the absence of increased external load. Recently, nonsurgical septal reduction therapy (NSRT) with intracoronary ethanol has been introduced to treat severely symptomatic patients with outflow tract obstruction. Its long-term effects on LV mass, however, are unknown. The LV size, function, and outflow tract gradient of 26 HOCM patients (53+/-15 years old) who underwent NSRT were assessed by echocardiography at baseline and 1 and 2 years after the procedure. LVH was evaluated by wall thickness of individual myocardial segments, planimetered myocardial area, and mass. The outflow gradient decreased from 36+/-6 mm Hg before NSRT to 0+/-3 mm Hg at 2 years (P<0.001), with patients experiencing symptomatic improvement (P<0.05). LV end-diastolic and end-systolic dimensions increased significantly at both 1 and 2 years (P<0.001). All parameters of LVH showed evidence of regression. LV mass decreased (301+/-78 g at baseline, 223+/-5 g at 1 year, and 190+/-58 g at 2 years; P<0.01), with the 2-year reduction in mass related to infarct size and the acute reduction in outflow tract gradient (r=0.48, P<0.05 and r=0.63, P<0.01, respectively). NSRT results in LV remodeling that is characterized by an increase in LV size and a decrease in the extent of LVH.

Regression of left ventricular hypertrophy after non-surgical septal reduction therapy for hypertrophic obstructive cardiomyopathy Wojciech Mazur, Sherif F. Nagueh, Nasser M. Lakkis, Katherine J. Middleton, Donna Killip, William H. Spencer, III. Baylor College of Medicine, Houston, TX, The Methodist Hospital, Houston, TX

Regression of left ventricular hypertrophy after non-surgical septal reduction therapy for hypertrophic obstructive cardiomyopathy Wojciech Mazur, Sherif F. Nagueh, Nasser M. Lakkis, Katherine J. Middleton, Donna Killip, William H. Spencer, III. Baylor College of Medicine, Houston, TX, The Methodist Hospital, Houston, TX

Echocardiographic insights into the mechanisms of relief of left ventricular outflow tract obstruction after nonsurgical septal reduction therapy in patients with hypertrophic obstructive cardiomyopathy

OBJECTIVESWe sought to evaluate the mechanisms by which nonsurgical septal reduction therapy (NSRT) reduces left ventricular outflow tract (LVOT) obstruction in patients with hypertrophic obstructive cardiomyopathy (HOCM) both acutely and on a long-term basis.BACKGROUNDNSRT reduces LVOT obstruction in patients with HOCM and leads to symptomatic improvement. The mechanisms involved, however, are not well studied.METHODSAn initial group of 30 HOCM patients (age 46 ± 17, 16 women) who underwent NSRT had echocardiographic studies performed at baseline and six months after the procedure. Measurements included LVOT diameter, end-diastolic distance between the anterior mitral leaflet and interventricular septum, septal base function and the angle between LV systolic flow and the protruding mitral leaflets. In addition, pulse Doppler recordings at a point 2.5 cm apical to the mitral valve were acquired and analyzed for peak and mean ejection velocity, peak acceleration rate and the ratio of acceleration time to ejection time (AT/ET).RESULTSSignificant changes were observed after the procedure, with widening in the LVOT, thinning and akinesis of the septal base, decrease in the angle between LV systolic flow and the protruding mitral leaflets, a decrease in peak acceleration rate and an increase in AT/ET. All of these variables had significant relations with the decrease in LVOT obstruction (r = 0.5 to 0.79, p < 0.01). These correlations were then evaluated in a test group of 15 patients who underwent echocardiographic examinations at baseline, acutely in the catheterization laboratory with ethanol injection and at six weeks post NSRT. Acute changes in peak acceleration rate (r = 0.65) and AT/ET (r = 0.73) related significantly (p < 0.01) to the decrease in LVOT obstruction with ethanol. At six weeks, changes similar to those noted in the initial group were observed in LVOT geometry, the angle between LV systolic flow and the protruding mitral leaflets, peak acceleration rate and AT/ET. In both populations combined, these parameters accounted for 72% to 77% of the variance in gradient reduction.CONCLUSIONSChanges in LV ejection dynamics and septal base function account in part for the acute relief of LVOT gradient after NSRT. The long-term relief of obstruction is dependent on remodeling of LVOT as well as the changes in LV ejection.

Nonsurgical septal reduction therapy for hypertrophic obstructive cardiomyopathy: one-year follow-up

OBJECTIVEThe objective of this study is to evaluate the one-year outcome of the first 50 patients who underwent nonsurgical septal reduction for symptomatic hypertrophic obstructive cardiomyopathy at our institution.BACKGROUNDLeft ventricular outflow tract obstruction is an important determinant of clinical symptoms in patients with hypertrophic obstructive cardiomyopathy. Nonsurgical septal reduction is a new therapy that has been shown to result in left ventricular outflow tract gradient reduction and resolution of symptoms immediately after the procedure and on midterm follow-up.METHODSFifty patients with hypertrophic obstructive cardiomyopathy who underwent nonsurgical septal reduction at our institution and completed 1-year follow-up are described. Complete history, physical examination, two-dimensional echocardiography with Doppler and exercise treadmill testing have been analyzed.RESULTSThe mean age of the study group was 53 ± 17 years. All patients had refractory symptoms before enrollment. Ninety-four percent had class III or IV New York Heart Association class symptoms at baseline compared to none at 1 year (p < 0.001). The exercise duration increased by 136 s at 1 year (p < 0.021). Only 20% of patients were either receiving beta-blockers or calcium-channel blockers on follow-up. The resting left ventricular outflow tract gradient decreased from 74 ± 23 mm Hg to 6 ± 18 mm Hg (p < 0.01) and from 84 ± 28 mm Hg to 30 ± 33 mm Hg (p < 0.01) in patients with dobutamine-provoked gradient at one year. These changes are associated with decreased septal thickness and preserved systolic function.CONCLUSIONNonsurgical septal reduction therapy is an effective therapy for symptomatic patients with hypertrophic obstructive cardiomyopathy with persistence of the favorable outcome up to one year after the procedure.

New treatment methods for patients with hypertrophic obstructive cardiomyopathy.

The past decade has witnessed significant advancements in the treatment of patients with refractory symptoms due to hypertrophic obstructive cardiomyopathy. In this publication, we will review the impact of dual-chamber pacing and nonsurgical septal reduction therapy with ethanol on the outcome of these patients. Both therapies have been shown to result in significant reductions in the left ventricular outflow gradient, which was an entry criterion in all the reported studies, along with symptomatic relief from symptoms of angina and dyspnea on midterm follow-up. Studies currently are under way to compare dual-chamber pacing and nonsurgical septal reduction therapy with myotomy-myomectomy, which is considered to be the standard of care in these patients.

Balloon positioning difficulties during nonsurgical septal reduction therapy in a patient with hypertrophic obstructive cardiomyopathy

Dual chamber (DDD) pacing and catheter-based nonsurgical septal reduction therapy (NSRT) with ethanol are evaluated for treatment of patients with hypertrophic cardiomyopathy. This report describes a patient with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction who had failed to respond to DDD pacing but showed benefit from subsequent NSRT. Procedural difficulties during NSRT due to massive septal hypertrophy are presented. Cathet. Cardiovasc. Intervent. 49:314–317, 2000. © 2000 Wiley-Liss, Inc.