Percutaneous Transluminal Septal Myocardial Ablation Research Articles

Changes in vortex and systolic anterior motion after percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy.

Changes in vortex and systolic anterior motion after percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy.

Predictive Factors for Decreasing Left Ventricular Ejection Fraction and Progression to the Dilated Phase of Hypertrophic Cardiomyopathy.

Patients with hypertrophic cardiomyopathy (HCM) may progress to the dilated phase (DHCM). This study aimed to identify the predictive factors for DHCM progression, including left ventricular (LV) ejection fraction (LVEF < 50%) or decreased LV contraction (LVEF < 60%). The study included 291 patients enrolled in our hospital's HCM registry who were grouped based on their poststudy LVEF (LVEF of ≥60%, 50-59%, and <50%). Predictive factors of an LVEF of <50% or <60% were determined. Further, the effects of percutaneous transluminal septal myocardial ablation (PTSMA) on long-term systolic LV function and DHCM development were investigated. LVEF was ≥60%, 50-59%, and <50% in 239, 33, and 19 patients, respectively, during the follow-up period (mean: 64.9 months). Multivariate analyses indicated baseline atrial fibrillation (AF), nonsustained ventricular tachycardia (NSVT), and left ventricular diameter at end-systole (LVDs) as significant predictors of DHCM. Using a scoring method based on AF, NSVT, and LVDs, patients with 2 and 3 points had a significantly higher risk of developing DHCM. PTSMA in 78 HCM patients demonstrated no significant effect on long-term LVEF changes or DHCM development. We concluded that AF, NSVT, and LVDs are significant predictors of DHCM development. However, a validation study with a larger population is required.

Percutaneous transluminal septal myocardial ablation for right ventricular outflow tract obstruction with repaired tetralogy of Fallot.

Percutaneous transluminal septal myocardial ablation for right ventricular outflow tract obstruction with repaired tetralogy of Fallot.

A Narrative Review of Emerging Therapies for Hypertrophic Obstructive Cardiomyopathy.

Hypertrophic obstructive cardiomyopathy is a hereditary condition that affects myocardial contraction. In case of failure of pharmacological treatment, alternative approaches might be used that include surgical myectomy, percutaneous transluminal septal myocardial ablation, and radiofrequency ablation. In respect of long-term advantages, surgical septal myectomy remains the therapy of choice for symptomatic hypertrophic obstructive cardiomyopathy. Alcohol septal ablation has been considered an alternative to surgical myectomy, which confers the benefits of a shorter hospital stay, less discomfort, and fewer complications. However, only expert operators should perform it on carefully chosen patients. Further, radiofrequency septal ablation reduces the left ventricular outflow tract gradient and improves the NYHA functional class of patients with hypertrophic obstructive cardiomyopathy, despite complications like cardiac tamponade and atrioventricular block. Further research with a larger sample size is required to compare the radiofrequency approach with established invasive treatment methods for hypertrophic obstructive cardiomyopathy. Septal myectomy has low morbidity and mortality rates, making it the preferred procedure; however, the efficacy and morbidity remain debatable. Advances in invasive techniques, including percutaneous septal radiofrequency ablation and transcatheter myotomy, have provided alternative approaches for reducing left ventricular outflow tract (LVOT) obstruction in patients who are not candidates for traditional surgical septal myectomy. Candidates for alcohol and radiofrequency septal ablation include patients with symptomatic hypertrophic obstructive cardiomyopathy, older adults, and those with multiple comorbidities.

Misplacement in myocardial contrast echo during alcohol septal ablation in hypertrophic obstructive cardiomyopathy indicates intraseptal collateralization.

A 42-year-old patient with HOCM was submitted for percutaneous transluminal septal myocardial ablation (PTSMA). Coronary angiography (Panel A) identified the first septal branch (SB) (yellow arrow) as estimated target vessel and a second SB (white arrow). Compared with intraprocedural baseline transthoracic echocardiography (TTE) (Panel B), myocardial contrast echocardiography (MCE) with injection of 1.5 mL cold gelafundin 4% through an inflated over the wire balloon catheter (OTW-BC) in the first SB (Panel C) identified a correct septal depot (orange arrow), but also opacification at the left ventricle apex (dotted orange arrow). Contrast dye injection through the OTW-BC (dotted yellow arrow) showed collateralization from the first (yellow arrow) into the second SB (yellow arrow) and drainage into the left anterior descending (LAD) (red arrow) as reason for the misplacement (Panel D). We placed a second OTW-BC in the collateralized second SB (dotted white arrow; Panel E). Contrast injection through both inflated OTW-BC showed only distal first (yellow arrow) and second SB (white arrow) without further collaterals and without drainage into the—in the meantime wired—LAD (red arrow). MCE (Panel E) showed only opacification of the targeted septal area (orange arrow) as TTE (Panel F) does after injection 1.5 cc of alcohol through each balloon. After deflation and retraction of the BCs, 10 min after alcohol injection, haemodynamic measurements ensured elimination of resting and provocable gradients. Final coronary angiography (Panel G) showed occluded SBs (arrows) and unchanged LAD.

Is There a Role for Alcohol Septal Ablation in Young Patients with Medically Refractory Hypertrophic Obstructive Cardiomyopathy?

Surgical myectomy is recommended for symptomatic hypertrophic obstructive cardiomyopathy (HOCM) after optimal pharmacological therapy. Percutaneous transluminal septal myocardial ablation (PTSMA) is reserved for high-risk adults. Symptomatic patients below 25years underwent either surgery or PTSMA after heart-team discussion and informed consent. Echocardiography assessed gradients in surgical group. PTSMA group underwent invasive transseptal hemodynamic assessment, selective coronary angiography and super-selective cannulation of septal perforators using microcatheters. Contrast echocardiography through the microcatheter identified the myocardial target for PTSMA. Hemodynamic and electrocardiographic monitoring guided alcohol injection. Both groups were continued on beta-blockers. Symptoms, echocardiographic gradients and Brain natriuretic peptide (NTproBNP) measurements were assessed on follow-up. Twelve patients aged 5-23years (11-98kg) formed the study group. Indications for PTSMA in 8 patients included abnormal mitral valve anatomy warranting replacement (n = 3), Jehovah's witness (n = 2), severe neurodevelopmental and growth retardation (n = 1) and refusal of surgery (n = 2). PTSMA targeted first perforator (n = 5), second perforator (n = 2) and anomalous septal artery from left main trunk (n = 1). Outflow gradient reduced from 92.5 ± 19.7 to 33.1 ± 13.5mmHg. At a median follow-up of 38months (range 3-120weeks), the peak instantaneous echocardiographic gradient was 32 ± 16.5mmHg. Gradient reduced in four surgical patients from 86.5 ± 16.3mmHg to 42 ± 14.7mm Hg. All patients were in NYHA class I/II on follow-up. The mean NTproBNP in PTSMA group reduced from 6084 ± 3628pg/ml to 3081 ± 2019pg/ml; it was 1396 and 1795pg/ml in surgery. PTSMA may be considered in medically refractory high-risk young patients. It relieves symptoms and reduces gradient. Though surgery is preferred in young patients, PTSMA may have a role in selected patients.

A novel risk model to predict all-cause mortality in patients undergoing percutaneous transluminal septal myocardial ablation for hypertrophic obstructive cardiomyopathy

Background and purpose: Hypertrophic obstructive cardiomyopathy (HOCM) is a global genetic myocardial disease. In clinical practice, an indicator that could be used to identify suitable patients for percutaneous transluminal septal myocardial ablation (PTSMA) and assess their long-term prognosis is important for cardiologists. HOCM patients undergoing PTSMA, poor long-term prognosis has been associated with higher left ventricular outflow tract gradient (LVOTG) and interventricular septal thickness (IVST). In this retrospective, multicenter study, we aimed to investigate the association between TG (TG = IVS thickness × LVOT gradient) index and acute- or long-term outcomes of HOCM patients after PTSMA and further investigate the interaction effects of LVOTG and IVST. Methods: The study design is based on four tertiary centers from Mid-China, and a total of 284 HOCM patients (132 males, average age 54.80 ± 11.98 years) were treated with PTSMA. A new clinic index (TG = IVS thickness × LVOT gradient) was designed. Both 30-day major cardiovascular adverse events and all-cause mortality of the HOCM patients were analyzed. Cox proportional hazards regression model adjusting for potential risk factors was applied to explore the hazard ratio (HR) for all-cause mortality. Results: Total alcohol injection volume was 2.201 ± 1.025 mL. LVOTG and IVST were reduced to 40.11 ± 24.44 mmHg and 17.68 ± 4.07 mm at the last clinical check-up, respectively. Patients with low IVST (≤20 mm) or low TG index (≤1,683) had a higher rate of PTSMA-contributable complications and a higher need for a permanent pacemaker. Within the 903 patient-years follow-up, a total of 21 (9.8%) deaths occurred. The number of deaths per 100 patient-years was 0.65 and 4.06 in the high versus low TG index groups. The 8-year OS rate was 48.95% (95% CI = 39.07%–57.75%) versus 82.63% (95% CI = 74.99%–86.66%) in the high versus low TG groups, respectively (log-rank P &lt; 0.001). The patients with both high LVOTG (&gt;82 mmHg) and high IVST had the highest risk of all-cause mortality (HR: 18.63 vs low LVOTG, 95% CI = 1.09–319.15). Conclusions: The 8-year OS rate was markedly higher in patients with a low TG index (≤1,683) (48.95%) versus in patients with a high TG index (&gt;1,683 group) (82.63%). The TG index could be a useful tool in the evaluation of HOCM patients for suitability for PTSMA.

Real-world clinical outcomes of percutaneous transluminal septal myocardial ablation for patients with drug-refractory hypertrophic obstructive cardiomyopathy: results from a retrospective multicenter registry of non-high-volume centers.

Percutaneous transluminal septal myocardial ablation (PTSMA) is a well-established interventional therapy for drug-refractory hypertrophic obstructive cardiomyopathy (HOCM) as an alternative to surgical myectomy. Although guidelines recommend that PTSMA should be performed in institutions with extensive experience, it is not centralized to such high-volume centers in real-world clinical practice. Thus, this study aimed to assess the feasibility of PTSMA in non-high-volume centers. We retrospectively examined patients with HOCM who underwent PTSMA between August 2012 and May 2020 at four institutions that experienced fewer than 20 cases of PTSMA procedures. The primary clinical endpoint was a composite of safety (all-cause death, electrical defibrillation for ventricular tachycardia or fibrillation, cardiac tamponade, permanent pacemaker implantation, and repeated interventions) and efficacyendpoints (repeated interventions [PTSMA or surgical myectomy]). Fifty-eight consecutive patients were enrolled. During the 30-day follow-up, no major clinical adverse events were noted except three patients (5.2%) requiring permanent pacemaker implantation for complete atrioventricular block. The percentage of patients with New York Heart Association functional class 1 or 2 significantly increased from 8.6 to 100% (p < 0.001). In the Cox proportional hazard model, left ventricular outflow tract pressure gradient at rest ≥ 30mmHg (hazard ratio [HR] 6.56; 95% confidence interval [CI] 1.44-29.90; p = 0.015) and mitral regurgitation grade ≥ 3 (HR 10.75; 95% CI 1.81-63.79; p = 0.009) at the 30-day follow-up were associated with a composite of major clinical adverse events. The current study demonstrated that 58 patients who underwent PTSMA in non-high-volume centers had favorable 30-day clinical outcomes, with a primary composite endpoint rate of 5.2%. A prospective study with a larger sample size and longer follow-up is warranted to verify the safety and efficacy of PTSMA in non-high-volume centers.

A Case of Hypertrophic Obstructive Cardiomyopathy Required Repeat Percutaneous Transluminal Septal Myocardial Ablation for Mid-Ventricular Obstruction After Release of Left Ventricular Outflow Tract in the First Percutaneous Transluminal Septal Myocardial Ablation

A Case of Hypertrophic Obstructive Cardiomyopathy Required Repeat Percutaneous Transluminal Septal Myocardial Ablation for Mid-Ventricular Obstruction After Release of Left Ventricular Outflow Tract in the First Percutaneous Transluminal Septal Myocardial Ablation

Prognostic Significance of Initial r-Wave in Leads V1 and aVR Before PTSMA in Patients with Hypertrophic Obstructive Cardiomyopathy.

ObjectivePercutaneous transluminal septal myocardial ablation (PTSMA) is one of the septal reduction therapies without all satisfactory results in hypertrophic obstructive cardiomyopathy (HOCM) patients. Initial r-wave in leads V1 and aVR on the surface electrocardiography is the sign of ventricular septal base depolarization. Whether the initial r-wave in leads V1 and aVR is predictive of good mid-term response to PTSMA in patients with HOCM remains unknown.Design, Settings, and ParticipantsAmong 546 consecutive patients evaluated in Fuwai Hospital (Beijing, China), we selected HOCM patients who underwent PTSMA. During the 3-year follow-up after PTSMA, primary outcomes included death, surgical myectomy, syncope, and NYHA classification III/IV.ResultsAt last, 85 patients were selected, and were assigned to 3 groups based on the presence of initial r-wave in leads V1 and aVR. Through multivariable Cox and Kaplan–Meier method, patients with initial r-wave in both leads V1 and aVR were independently associated with a decreased risk of primary outcomes (HR: 0.112; 95% CI: 0.024 to 0.518; p = 0.005) during 3-years’ follow-up.ConclusionThe results suggest that the presence of initial r-wave in both leads V1 and aVR on the surface 12-lead ECG is highly predictive of good mid-term response to PTSMA in patients with HOCM.

The role of echocardiography in percutaneous transluminal septal myocardial ablation for obstructive hypertrophic cardiomyopathy

The role of echocardiography in percutaneous transluminal septal myocardial ablation for obstructive hypertrophic cardiomyopathy

Percutaneous transluminal septal myocardial ablation markedly reduces energy loss in hypertrophic obstructive cardiomyopathy: a four-dimensional flow magnetic resonance imaging study

Abstract Background Functional follow-up modalities of hypertrophic obstructive cardiomyopathy (HOCM) subjected to percutaneous transluminal septal myocardial ablation (PTSMA) are limited mainly to echocardiography and catheterization. Recent advancements in four-dimensional (4D) flow magnetic resonance imaging (MRI) have enabled us to assess patients from the perspective of fluid dynamics by visualising blood flow and calculating quantitative parameters such as wall shear stress and energy loss within cardiac chambers or blood vessels. Several reports have demonstrated that the intra-cardiac energy loss decreased along with improvement of cardiac function achieved by treatment of cardiac diseases. Whether changes in energy loss occur along with PTSMA in HOCM patients and the underlying mechanism remain unknown. Purpose This study sought to investigate the influence of PTSMA in patients with HOCM on energy loss in the left ventricle (LV) and aortic root measured by 4D flow MRI. Methods We retrospectively recruited HOCM patients who underwent PTSMA at a referral centre from May to November 2019. Patients who underwent 4D flow MRI both before and after PTSMA were included. We collected demographic and clinical data from electronic health records. MRI scans implemented two-dimensional phase-contrast imaging of the three-chamber plane with three-directional velocity, using a 1.5 T scanner. Furthermore, 4D blood flow analysis was performed on off-line saved data, using iTFlow version 1.9. We assessed energy loss in one cardiac cycle within the three-chamber plane of the LV and aortic root (area surrounded by the LV endocardium, sinotubular junction, and mitral annulus). Results This study finally included 12 patients, whose mean age was 66±12 years, and 5 (42%) of whom were men. The pressure gradient between the LV apex and ascending aorta was 81±32 mmHg before and 20±22 mmHg immediately after PTSMA (P&amp;lt;0.005, paired). Before PTSMA, 6 patients were in New York Heart Association functional class III and the other 6 in class II. However, after PTSMA, 10 patients improved to class I and 2 to class II. PTSMA reduced energy loss in one cardiac cycle within the three-chamber plane of the LV and aortic root, from 79±36 mJ/m to 55±19 mJ/m (P=0.001, paired). Conclusions PTSMA in patients with HOCM reduced energy loss within the LV and aortic root, indicating significant decrease with cardiac workload. Four-dimensional flow MRI of the three-chamber plane to assess energy loss within the LV and aortic root is a time-efficient and reproducible quantitative method to evaluate the effects of PTSMA. Given its non-invasive nature, it also enables to sequentially follow-up HOCM patients who underwent PTSMA. Periprocedural changes of energy loss Funding Acknowledgement Type of funding source: None

Reverse remodeling after percutaneous transluminal septal myocardial ablation in severe but asymptomatic LVOT obstruction (RASTA) study: Rationale and design of transcatheter septal reduction in asymptomatic patients with severe hypertrophic obstructive cardiomyopathy.

The aim of this study is to evaluate the impact of percutaneous transluminal septal myocardial ablation (PTSMA) on remodeling in asymptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) and severe left ventricular outflow tract (LVOT) obstruction. Symptoms justify invasive treatment in HOCM patients with LVOT obstruction. Adverse structural and functional changes (remodeling) in the heart occur preceding heart failure and sudden cardiac death. Early invasive treatment in asymptomatic patients may reverse adverse remodeling to the same extent as in symptomatic patients. Reverse remodeling after PTSMA in severe but asymptomatic LVOT obstruction (RASTA) study is a prospective single-blind randomized trial (ClinicalTrials.gov number: NCT04230551). Ten asymptomatic HOCM patients with an exertional LVOT gradient ≥50 mmHg (or >30 mmHg in rest) are randomized 1:1 to PTSMA versus conservative therapy, in the absence of mitral valve disease or other indications for cardiac surgery. Five symptomatic (reference group) will undergo PTSMA according to the current guidelines. Remodeling is assessed using extensive cardiac imaging with transthoracic echocardiography and late gadolinium enhancement cardiac magnetic resonance at baseline and during follow-up at 1, 12, and 24 months. Extracellular volume fraction, global, and regional strain analysis, geometry, pressure gradients and changes in four-dimensional velocity mapping are primary parameters to study (reversal of) adverse remodeling. The RASTA study gives insight in cardiac remodeling that may occur in asymptomatic patients after PTSMA. It will provide arguments whether to pursue (or not) a larger trial with clinical endpoints in asymptomatic HOCM patients with severe LVOT obstruction.

Differences in routes of guiding catheters for left coronary artery according to access sites assessed by the combined angiography-computed tomography system.

Differences in guiding catheters (GCs) manipulations and selections among different access sites are currently unclear. We examined the differences in the routes of GCs for the left coronary artery (LCA) among the right radial, left radial, and femoral approaches. We used a combined angiography-computed tomography (CT) system that enabled to perform CT scans during percutaneous coronary intervention (PCI). We enrolled 88 patients who underwent CT scans during LCA PCI or percutaneous transluminal septal myocardial ablation. To evaluate the route of GCs, we analyzed the positions of the catheter's contact point on the contralateral aortic wall to the LCA ostium, which were expressed by the angle formed by the vertical line and the diagonal line from the GC shaft to the center of the aorta. The procedures were performed via the right radial in 47 cases, left radial in 20, and femoral approach in 21. The positions of the catheter's contact point were significantly different depending on the approaches (interquartile range -3.7 [-14.3 to 7.8], -46.5 [-76.9 to -9.3], and -30.7 [-39.4 to -22.4] degrees, respectively; p < 0.001). Multivariate analysis demonstrated that access sites and LCA ostium locations had significant impacts on the positions of the catheter's contact point. The routes of LCA GCs were different among the right radial, left radial, and femoral approaches.

Percutaneous transluminal septal myocardial ablation for hypertrophic obstructive cardiomyopathy through non-left anterior descending septal perforators.

Percutaneous transluminal septal myocardial ablation (PTSMA) has become a significant treatment for symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) despite maximal medical therapy. The target septal arteries usually arise from the left anterior descending artery (LAD). However, when septal perforators do not originate from the LAD, non-LAD septal perforators should be included as candidate-target septal branches that feed the hypertrophic septal myocardium, causing left ventricular outflow tract (LVOT) obstruction. Data pertaining to the procedure remain limited. We aimed to investigate PTSMA through the non-LAD septal perforators in patients with HOCM. In this case series review, we evaluated the baseline characteristics, echocardiographic features, and angiographic features, as well as symptoms and pressure gradient before and after PTSMA through the non-LAD septal perforators. Among 202 consecutive patients who underwent PTSMA for HOCM with LVOT obstruction, 21 had non-LAD septal branches that fed the hypertrophic septal myocardium and received alcohol ablation. Non-LAD septal perforators could be used as an alternative route for PTSMA in patients who experienced ineffective ablation of the septal branch that arises from the LAD. This unique procedure may improve response rates and overall outcomes of patients with HOCM.

Percutaneous Transluminal Septal Myocardial Ablation to a Pre-Procedural Coronary Computed Tomography Angiography-Detected Anomalous Septal Branch.

Percutaneous Transluminal Septal Myocardial Ablation to a Pre-Procedural Coronary Computed Tomography Angiography-Detected Anomalous Septal Branch.

Four-dimensional flow magnetic resonance imaging reveals the reduction in turbulent kinetic energy after percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy.

Four-dimensional flow magnetic resonance imaging reveals the reduction in turbulent kinetic energy after percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy.

大動脈弁狭窄症を合併したsigmoid septumによる左室流出路狭窄に対して，経皮的中隔心筋焼灼術が著効した1例

大動脈弁狭窄症を合併したsigmoid septumによる左室流出路狭窄に対して，経皮的中隔心筋焼灼術が著効した1例

Retrospective Analysis of Risk Factors for Related Complications of Chemical Ablation on Hypertrophic Obstructive Cardiomyopathy.

BackgroundThe analysis of risk factors for predicting related complications has not been reported to date.ObjectiveThis study aims to investigate the risk factors of related complications of percutaneous transluminal septal myocardial ablation (PTSMA) for hypertrophic obstructive cardiomyopathy (HOCM) retrospectively.MethodClinical data, and one-year follow-up results of patients with HOCM, who underwent PTSMA between January 2000 and July 2013 in the Department of Cardiology, Liaoning Province People’s Hospital, Liaoning Province, China, were retrospectively analyzed to determine risk factors for operative complications with multiple logistic regression analysis. All p values are two-sided, with values of p < 0.05 being considered statistically significant.ResultsAmong 319 patients with HOCM, PTSMA was performed in 224 patients (120 males and 104 females, mean age was 48.20 ± 14.34 years old). The incidence of PTSMA procedure-related complications was 36.23% (66/224), which included three cardiac deaths, two cardiac shocks, one ST-segment elevated myocardial infarction, two ventricular fibrillations, 20 third-degree atrioventricular (AV) blocks (four patients were implanted with a permanent pacemaker (PPM)), 32 complete right bundle branch blocks, two complete left bundle branch blocks, and four puncture-related complications. After multivariate logistic regression analysis, it was found that age, gender, coronary artery diseases, diabetes, heart rate, cardiac function on admission, the number of septal ablations, and the volume of alcohol were not independent risk factors correlated to the whole complications, except for hypertension (OR: 4.856; 95% CI: 1.732-13.609). Early experience appears to be associated with the occurrence of complications.ConclusionHypertension was an independent risk factor for PTSMA procedure-related complications. It might be much safer and more efficient if PTSMA procedures are restricted to experienced centers, according to the analysis results for the learning curve.

Percutaneous transluminal septal myocardial ablation for persistant left ventricular outflow tract obstruction after combined aortic valve replacement and septal myectomy in severe aortic stenosis

Percutaneous transluminal septal myocardial ablation for persistant left ventricular outflow tract obstruction after combined aortic valve replacement and septal myectomy in severe aortic stenosis