Alcohol septal ablation in patients aged 75 years or older with hypertrophic obstructive cardiomyopathy.

OBJECTIVE: Outcome data for patients ≥75 years with hypertrophic obstructive cardiomyopathy (HOCM) undergoing alcohol septal ablation (ASA) are lacking. Therefore, a retrospective single-centre analysis was conducted. METHODS: The data of all consecutive ASAs, that were performed at our institution between 1 September 1997 and 31 July 2021 in patients with HOCM with left ventricular outflow tract gradients (LVOTG) ≥50 mm Hg, were collected from patient reports. ASA was performed per institutional standards with 95% ethanol infused into a feasible septal branch. Differences regarding echocardiographic, procedural and clinical parameters at baseline and after 6 months between patients ≥75 years and <75 years were assessed. RESULTS: We found 208 ASAs in patients ≥75 years (85.1% female; age 78.0 years (IQR 76.0-80.0)) and 1430 ASAs in patients <75 years (42.0% female; age 56.0 years (IQR 46.0-65.0)). Patients ≥75 years had lower distances in 6 min walk test (baseline: 317.0 m (IQR 242.0-389.0) vs 438.0 m (IQR 353.3-504.0); p<0.0001). Exercise-induced LVOTG calculated at follow-up was lower in patients ≥75 years (29.5 mm Hg (IQR 18.0-54.0) vs 39.5 mm Hg (IQR 23.0-73.8); p=0.0007). There were more high-degree AV blocks after ASA in patients ≥75 years (25.5% vs 13.6%; p<0.0001). The in-hospital mortality did not differ between the groups (age ≥75 years: 1.0%; age <75 years: 0.6%; p=0.6580). CONCLUSION: ASA had similar efficacy and intrahospital mortality in patients ≥75 years compared with younger patients. Higher rates of AV block with need for permanent pacemaker implantation were observed in patients ≥75 years of age.

Case report of a patient with congenital long QT syndrome Type 2 presenting with electrical storm: do not judge a book by its cover!

Background: Patients with congenital long QT syndrome (LQTS) are at high risk for sudden cardiac death (SCD). Although several triggers can provoke ventricular fibrillation (VF) in patients suffering from LQTS acquired heart disease in addition to LQTS should not be overlooked. Case summary: We present a case of a 47-year-old female patient who was diagnosed with congenital LQTS Type 2 at the age of 23 after surviving SCD. At that time, she underwent implantable cardioverter-defibrillator (ICD) implantation and was free of events for 24 years. Recently, the patient was referred to our institution after suffering from an ICD shock during sleep. Upon arrival she developed electrical storm and received overall six ICD shocks. The initial electrocardiogram (ECG) showed atrially triggered ventricular pacing. However, distinct ST segment elevations in the inferior leads could be observed. Thus, coronary angiography was immediately performed and showed subtotal occlusion of the right coronary artery, which was treated by drug-eluting stent implantation. Atrioventricular conduction immediately resumed after revascularization and the following non-paced ECG revealed a prolonged QT interval. Laboratory measurements confirmed acute myocardial infarction with elevated cardiac enzymes. The patient was put on betablockers, dual antiplatelet therapy, and statins and discharged in good condition. Discussion: This case report highlights that diagnostic work-up in patients with LQTS presenting with VF should always include the search for additional acquired heart disease such as myocardial infarction, as a potential trigger for electrical storm. Moreover, signs of ischaemia can be discerned even in a paced ECG which should lead to immediate cardiac catheterization.

Gender disparities in alcohol septal ablation for hypertrophic obstructive cardiomyopathy.

OBJECTIVE: Alcohol septal ablation (ASA) improves symptoms in hypertrophic obstructive cardiomyopathy (HOCM). We conducted a large retrospective analysis investigating gender effects on outcome after ASA. METHODS AND RESULTS: 1367 ASAs between 2002 and 2020 were analysed. Women (47.2%) were older (66.0 years (IQR 55.0-74.0) vs 54.0 years (IQR 45.0-62.0); p<0.0001) with more severe symptoms. The interventricular septal diameter (IVSD) was higher in men (21.0 mm (IQR 19.0-24.0) vs 20.0 mm (IQR 18.0-23.0); p<0.0001) but the IVSD indexed to body surface area was higher in women (10.9 mm/m2 (IQR 9.7-12.7) vs 10.2 mm/m2 (IQR 9.0-11.7); p<0.0001). Women had lower exercise-induced left ventricular outflow tract gradients (LVOTG) 1-4 days after ASA (55.0 mm Hg (IQR 30.0-109.0) vs 71.0 mm Hg (IQR 37.0-115.0); p=0.0006). There was a trend for lower resting LVOTG 1-4 days after ASA (20.0 mm Hg (IQR 12.0-37.5) vs 22.0 mm Hg (IQR 13.0-40.0); p=0.0062) and lower exercise-induced LVOTG after 6 months in women (34.0 mm Hg (IQR 21.0-70.0) vs 43.5 mm Hg (IQR 25.0-74.8); p=0.0072), but this was not statistically significant after Bonferroni correction. More women developed atrioventricular (AV) block (20.3% vs 13.3%; p=0.0005) and required a pacemaker (17.4% vs 10.4%; p=0.0002) but not a cardioverter defibrillator (9.0% vs 11.6% in men; p=n .s.). However, in multivariable regression models, there was no evidence that sex independently influenced LVOTG and the occurrence of AV block. CONCLUSION: Female patients with HOCM were older and had more advanced disease at the time of ASA. Women had superior short-term haemodynamic response to ASA but more often developed AV block after ASA. These results are important to consider for sex-specific counselling before ASA.