Peak systolic longitudinal strain of the lateral left ventricular wall improves after septal ablation for symptomatic hypertrophic obstructive cardiomyopathy: a follow-up study using speckle tracking echocardiography.

Speckle tracking echocardiography (STE) or two-dimensional (2D) strain imaging is a novel ultrasound method to assess myocardial deformation. Peak systolic longitudinal strain (PSLS) of the basal septum (IVS) and the opposite lateral (LVFW) wall were measured in addition to standard echocardiography in 88 consecutive patients (pts) with obstructive hypertrophic cardiomyopathy (HOCM) who underwent a septal ablation procedure (PTSMA) and who were re-evaluated 12 ± 12 after months. At baseline, PSLS was substantially reduced both in basal regions. While PSLS remained unchanged in the basal IVS, i.e. the target region for PTSMA (baseline: -5.3 ± 4.1%; follow-up: -6.0 ± 4.3%; P=0.06), it improved in the opposite LVFW (from -9.4 ± 4.7 to -12.4 ± 4.8%; P<0.0001). Wall thickness decreased in both regions (Septum: from 20 ± 4 to 17 ± 4 mm; P<0.0001; LV free wall: from 13 ± 2 to 12 ± 2 mm; P=0.001). PSLS correlated significantly with wall thickness, both at baseline and at follow-up. NYHA functional class (from 2.9 ± 0.4 to 1.6 ± 0.6; P<0.0001) and objective exercise capacity (from 96 ± 42 to 114 ± 42 W; P=0.001) improved together with the reduction of outflow obstruction (LVOTO: from 62 ± 30 to 11 ± 19 mm Hg at rest, from 121 ± 26 to 43 ± 40 mm Hg with provocation; P<0.0001). During the 12 months of observation, no patient had a severe adverse event. Regional myocardial deformation can be assessed quantitatively by STE. Reduction of LV afterload by elimination of the outflow gradient following a successful PTSMA with low doses of alcohol results in improvement of systolic lateral longitudinal function.

The potential of multi-slice computed tomography based volumetry for demonstrating reverse remodeling induced by cardiac resynchronization therapy.

BACKGROUND: Multi-slice computed tomography (MSCT) was proved to provide precise cardiac volumetric assessment. Cardiac resynchronization therapy (CRT) is an effective treatment for selected patients with heart failure and reduced ejection fraction (HFREF). In HFREF patients we investigated the potential of MSCT based wall motion analysis in order to demonstrate CRT-induced reversed remodeling. METHODS: Besides six patients with normal cardiac pump function serving as control group seven HFREF patients underwent contrast enhanced MSCT before and after CRT. Short cardiac axis views of the left ventricle (LV) in end-diastole (ED) and end-systole (ES) served for planimetry. Pre- and post-CRT MSCT based volumetry was compared with 2D echo. To demonstrate CRT-induced reverse remodeling, MSCT based multi-segment color-coded polar maps were introduced. RESULTS: With regard to the HFREF patients pre-CRT MSCT based volumetry correlated with 2D echo data for LV-EDV (MSCT 278.3+/-75.0mL vs. echo 274.4+/-85.6mL) r=0.380, p=0.401, LV-ESV (MSCT 226.7+/-75.4mL vs. echo 220.1+/-74.0mL) r=0.323, p=0.479 and LV-EF (MSCT 20.2+/-8.8% vs. echo 20.0+/-11.9%) r=0.617, p=0.143. Post-CRT MSCT correlated well with 2D echo: LV-EDV (MSCT 218.9+/-106.4mL vs. echo 188.7+/-93.1mL) r=0.87, p=0.011, LV-ESV (MSCT 145+/-71.5mL vs. echo 125.6+/-78mL) r=0.84, p=0.018 and LV-EF (MSCT 29.6+/-11.3mL vs. echo 38.6+/-14.6mL) r=0.89, p=0.007. There was a significant increase of the mid-ventricular septum in terms of absolute LV wall thickening of the responders (pre 0.9+/-2.1mm vs. post 3.3+/-2.2mm; p<0.0005). CONCLUSION: MSCT based volumetry involving multi-segment color-coded polar maps offers wall motion analysis to demonstrate CRT-induced reverse remodeling which needs to be further validated.

Percutaneous septal ablation after unsuccessful surgical myectomy for patients with hypertrophic obstructive cardiomyopathy.

OBJECTIVE: To evaluate the long-term outcome of percutaneous septal ablation (PTSMA) after a previous myectomy. BACKGROUND: Myectomy usually results in symptomatic improvement and reduction of dynamic obstruction in hypertrophic obstructive cardiomyopathy patients (HOCM-pts.). However, a few pts. remain with severe symptoms and obstruction, and need additional interventions. METHODS: We reviewed our database of 450 pts. who underwent PTSMA in our institution, and identified 11 (7 women, 4 men, mean age: 50 +/- 14 years) with residual or recurrent NYHA class symptoms > or =III and significant left ventricular outflow obstruction (LVOTO) despite a previous myectomy 4 +/- 5 years ago. In-hospital and follow-up data covering 6 +/- 4 years, focusing on mortality and morbidity, symptoms, exercise capacity, and echocardiographic measures were collected. RESULTS: PTSMA was performed by injection of 3.6 +/- 2.9 ml of alcohol. There was no peri-procedural or late death in this cohort. CK peaked at 614 +/- 434 U/l. In addition to two pts. who already had a pacemaker implanted, two more (18%) who both had pre-existing left bundle branch block were pacemaker-dependent after PTSMA. During follow-up, 9 pts. (81%) reported significant and stable improvement. Two pts. (18%) developed progressive class III symptoms until their last follow-up, one of these together with persistent AF and a non-fatal stroke, the other received an ICD for primary prophylaxis and entered our pre-transplant program. Echo-Doppler showed sustained LVOTO elimination without global LV dilatation in all cases. CONCLUSIONS: PTSMA is an effective non-surgical option for treating symptoms and residual or recurrent LVOTO after a previous surgical myectomy. The high rate of conduction disturbances in this post-surgical cohort translated into a higher rate of pacemaker dependency after PTSMA.

Percutaneous septal ablation for symptomatic hypertrophic obstructive cardiomyopathy: managing the risk of procedure-related AV conduction disturbances.

AIM: To provide tools for predicting the course of AV conduction disturbances after ethanol-induced septal ablation (PTSMA) for hypertrophic obstructive cardiomyopathy (HOCM). METHODS AND RESULTS: Based on a scoring system developed 1996-1998 and including parameters from baseline ECG, heart rate profile, severity of outflow obstruction (LVOTO), peri-interventional enzyme kinetics, and peri-interventional conduction problems, the risk of permanent AV block following PTSMA was assessed in 155 consecutive HOCM patients (pts.; mean age: 53+/-13 years) between 1999 and 2004. During PTSMA with 2.1+/-0.5 ml of ethanol, transient complete AV block occurred in 71 pts. (46%). Pts. were grouped into a low, intermediate, and high risk group for permanent conduction damage, and treated accordingly (early discharge from monitoring, prolonged monitoring, early DDD-PM implantation). Permanent pacing was necessary in 11 cases (7%), 0/116 of these (0%) in the low, 4/31 (13%) in the intermediate, and 7/8 (87%) in the high-risk group. While a new right bundle branch block was the most frequent ECG finding after PTSMA, a left bundle branch block at baseline was associated with 4 of the 11 DDD-PM implantations (p<0.0001). In-hospital mortality was 0%, short-term (3-months) follow up was complete. During follow-up, AV conduction recovered in 4 pts. (46%) with a DDD-PM. New onset AV blocks did not occur. Significant improvement of symptoms was reported by 141 pts. (91%). CONCLUSIONS: Catheter-based septal ablation is an effective non-surgical technique for reducing symptoms and outflow gradients in HOCM. The proposed scoring system appears to reliably discriminate pts. with a high risk for permanent PM dependency from those with stable AV conduction after PTSMA. Pts. with left bundle branch block at baseline should undergo DDD-PM implantation prior to ablation.

Percutaneous septal ablation in hypertrophic obstructive cardiomyopathy: current status.

This article reviews aetiology, natural history, and current treatment options in hypertrophic cardiomyopathy with a special focus on percutaneous septal ablation, which has evolved as an alternative to myectomy in patients with outflow obstruction and symptoms refractory to medical treatment. Literature data and the own series of 382 interventions (in-hospital mortality and pacemaker implantation rates: 1.2% and 7%, respectively) are discussed. Overall satisfactory clinical results were seen in about 90% of the patients treated with septal ablation.

Quantitative analysis of intraprocedural myocardial contrast echocardiography during percutaneous septal ablation for hypertrophic obstructive cardiomyopathy.

AIMS: We tested whether procedural success of percutaneous septal ablation for hypertrophic obstructive cardiomyopathy is related to quantitative measurements of intraprocedural myocardial contrast echocardiography. METHODS AND RESULTS: In a study group of 34 patients, the mean area of the contrast depot was 8.5+/-2.5 cm2, its length along the left ventricular endocardial border 3.0+/-0.7 cm and its proximal edge 2.0+/-0.6 cm upstream the point of mitral-septal contact. Clinical and hemodynamic success was achieved in all but one patient 3 months following percutaneous septal ablation. The proximal edge of the ablation lesion correlated weakly (r=0.5) with the proximal edge of the contrast depot with respect to their distance from the mitral valve leaflet tips. No other correlations were found between the efficacy of percutaneous septal ablation and various quantitative measurements of intraprocedural contrast echocardiography. CONCLUSIONS: The localization of the ablation lesion 3 months after percutaneous septal ablation is predicted by the localization of the contrast depot with respect to the point of mitral-septal contact. The final hemodynamic effect of the ablation lesion, however, does not correlate with quantitative parameters of intraprocedural contrast echocardiography, but appears to be the result of an individual remodeling process.

Echo-guided percutaneous septal ablation for symptomatic hypertrophic obstructive cardiomyopathy: 7 years of experience.

AIMS: To analyze the impact of intra-procedural echocardiographic imaging on the interventional strategy in ethanol-induced septal ablation (PTSMA) for symptomatic hypertrophic obstructive cardiomyopathy (HOCM), based on a single-center experience of 7 years. METHODS AND RESULTS: PTSMA was intended for refractory symptoms in 337 patients (pts.) with HOCM (mean age: 54 +/- 15 years), with 312 procedures completed by injection of 2.8 +/- 1.2 ml ethanol. In 25 pts. (8%) the intervention was aborted without ethanol injection, mostly because of echocardiographic findings (n = 18/6%). An echocardiography-driven target vessel change was necessary in 33 pts. (11%). In the 312 pts. who received ethanol, permanent pacing was necessary in 22 cases (7%). In-hospital mortality was 1.3% (4 pts.). After 3 months, mean NYHA functional class was reduced from 2.9 +/- 0.5 to 1.5 +/- 0.6 (p < 0.0001) along with a gradient reduction from 60 +/- 33 to 13 +/- 18 mmHg at rest, and from 120 +/- 43 to 38 +/- 35 mmHg with provocation (p < 0.0001 each). Exercise capacity improved from 94 +/- 51 to 115 +/- 43 W, peak oxygen consumption from 18 +/- 4 to 21 +/- 6 ml/kg/min (p < 0.01 each). There was no significant difference regarding residual gradients in pts. with different levels of immediate gradient reduction during probatory balloon occlusion. CONCLUSIONS: Catheter-based septal ablation is an effective non-surgical technique for reducing symptoms and outflow gradients in HOCM. Intra-procedural echocardiographic guidance has a cumulative impact on the interventional strategy in about 15-20%, and clearly identifies pts. who should not receive ethanol but undergo a surgical myectomy.