Correspondence
The Management of Hypertrophic Cardiomyopathy
N Engl J Med 1997; 337:349-350July 31, 1997
- Article
To the Editor:
With regard to the excellent review article by Spirito et al. (March 13 issue),1 we wish to report data on percutaneous transluminal septal myocardial ablation, which Sigwart introduced in 1995 as a new option for the treatment of highly symptomatic patients with hypertrophic obstructive cardiomyopathy.2 Since January 1996,3 we have used this technique of nonsurgical myocardial ablation by alcohol-induced occlusion of the first septal perforation in 56 highly symptomatic patients (mean [±SD] New York Heart Association functional class, 2.7±0.6). The left ventricular outflow tract gradient was reduced in 93 percent of patients (eliminated in 27 percent, reduced by at least 50 percent in 52 percent, and reduced by 20 to 49 percent in 7 percent; mean reduction with the patient at rest, from 68.1±32.7 to 18.2±21.6 mm Hg; after an extrasystole, 141.6±40.7 to 63.6±49.1 mm Hg). In four patients whose primary treatments failed, the ablation technique was repeated successfully when the target septal branch was identified by myocardial contrast echocardiography.4
The most frequent complication was permanent trifascicular block in 14 percent of the patients, which required the implantation of a DDD pacemaker. A new bundle-branch block developed in 50 percent of the patients. During the injection of the alcohol, neither ventricular fibrillation nor septal perforation was seen in this cohort. Two patients (4 percent) died in the hospital from complications unrelated to the procedure. At the three-month follow-up visit, 35 patients had excellent clinical improvement (New York Heart Association class, 1.3±1.1; P<0.001); there was ongoing reduction of the outflow gradient in 56 percent of the patients. No septal perforation or noncardiac complications were seen during follow-up.5
5 ReferencesHubert Seggewiss, M.D.
Ulrich Gleichmann, M.D.
Lothar Faber, M.D.
University Hospital of the Ruhr University of Bochum, 32545 Bad Oeynhausen, Germany1
Spirito P ,Seidman CE ,McKenna WJ ,Maron BJ . The management of hypertrophic cardiomyopathy. N Engl J Med 1997;336:775-785
Full Text | Web of Science | Medline2
Sigwart U . Non-surgical myocardial reduction for hypertrophic obstructive cardiomyopathy. Lancet 1995;346:211-214
CrossRef | Web of Science | Medline3
Gleichmann U ,Seggewiss H ,Faber L ,Fassbender D ,Schmidt HK ,Strick S . Kathetertherapie der hypertrophen obstruktiven Kardiomyopathie. Dtsch Med Wochenschr 1996;121:679-685
CrossRef | Web of Science | Medline4
Faber L, Seggewiss H, Fassbender D, Strick S, Bogunovic N, Gleichmann U. Guiding of interventional myocardial ablation in obstructive hypertrophic cardiomyopathy by myocardial contrast echocardiography (MCE): first experiences. Presented at the 8th Essen–Mayo–Mainz-Symposium, Essen, Germany, October 25–27, 1996. abstract.
5
Seggewiss H ,Gleichmann U ,Faber L ,Fassbender D ,Schmidt HK ,Strick S . Catheter treatment of hypertrophic obstructive cardiomyopathy: acute and mid-term results. J Am Coll Cardiol 1997;29:Suppl A:388A-388A abstract.
Author/Editor Response
The authors reply:
To the Editor: Seggewiss et al. address the potential role of nonsurgical partial septal ablation in hypertrophic obstructive cardiomyopathy. In this procedure, absolute ethanol is injected into a septal perforator artery to produce a localized myocardial infarction. This novel approach is being offered experimentally at a few selected centers as an alternative to ventricular septal myotomy–myectomy.1-3 However, a number of important considerations pertaining to the technique deserve emphasis.
First, although much of the clinical experience with septal ablation in patients with hypertrophic obstructive cardiomyopathy is still unpublished, the mortality and morbidity associated with the procedure (including complete atrioventricular block requiring the permanent implantation of a pacemaker) are unacceptably high at some centers and may in fact exceed those associated with septal myotomy–myectomy. Indeed, standard surgical intervention for hypertrophic obstructive cardiomyopathy is now performed with low operative risk (less than 1 to 2 percent mortality) at selected centers, and it has long-term benefits, with substantial reduction or abolition of the outflow gradient in more than 90 percent of patients and marked improvement in symptoms in 70 percent.4
Second, a substantial proportion of patients with hypertrophic obstructive cardiomyopathy have a benign clinical course, with only mild symptoms or none, and they may have a normal life span.4 Such patients do not require a profoundly aggressive procedure that is designed to produce a controlled myocardial infarction (with its associated risks) to reduce an outflow gradient that in itself may not necessarily influence prognosis. Consequently, septal ablation would theoretically be justified only in patients with severe symptoms refractory to drug therapy (New York Heart Association functional class III or IV), as an alternative to surgery. Unfortunately, up to 40 percent of patients who have undergone alcohol ablation at selected institutions were not severely symptomatic but, rather, had only mild symptoms or were even asymptomatic.1
Third, although the preliminary data suggest that partial septal ablation may reduce the outflow gradient in many patients with hypertrophic obstructive cardiomyopathy (as Seggewiss et al. point out), there are no data to substantiate that the procedure improves symptoms or enhances exercise capacity. Indeed, we have already observed the substantial placebo effect that may be produced in symptomatic patients with this condition by experimental techniques focused on reducing the outflow gradient, such as dual-chamber pacing.5
Furthermore, the high rate at which permanent or temporary pacemakers are implanted for complete heart block after alcohol ablation (up to 33 percent in some centers) represents an important complication that is rare with myotomy–myectomy and is also a confounding factor in assessing whether ablation itself benefits left ventricular hemodynamics (since the pacemaker may contribute to reducing the gradient). Obviously, the long-term hemodynamic and functional consequences of alcohol-induced septal ablation are unknown at this early stage.
5 ReferencesBarry J. Maron, M.D.
Minneapolis Heart Institute Foundation, Minneapolis, MN 55407Paolo Spirito, M.D.
Ospedale S. Andrea, 19100 La Spezia, ItalyWilliam J. McKenna, M.D.
St. George's Hospital Medical School, London SW17 0RE, United KingdomChristine E. Seidman, M.D.
Harvard Medical School, Boston, MA 021151
Knight C ,Kurbaan AS ,Seggewiss H , et al. Nonsurgical septal reduction for hypertrophic cardiomyopathy: outcome in the first series of patients. Circulation 1997;95:2075-2081
Web of Science | Medline2
Lakkis N ,Kleiman N ,Killip D ,Spencer WH III . Hypertrophic obstructive cardiomyopathy: alternative therapeutic options. Clin Cardiol 1997;20:417-418
CrossRef | Web of Science | Medline3
Seggewiss H ,Gleichmann U ,Faber L ,Fassbender D ,Schmidt HK ,Strick S . Catheter treatment of hypertrophic obstructive cardiomyopathy: acute and mid-term results. J Am Coll Cardiol 1997;29:Suppl A:388A-388A abstract.4
Spirito P ,Seidman CE ,McKenna WJ ,Maron BJ . The management of hypertrophic cardiomyopathy. N Engl J Med 1997;336:775-785
Full Text | Web of Science | Medline5
Nishimura RA ,Trusty JM ,Hayes DL , et al. Dual-chamber pacing for hypertrophic cardiomyopathy: a randomized, double-blind, crossover trial. J Am Coll Cardiol 1997;29:435-441
CrossRef | Web of Science | Medline
- Citing Articles (3)
Citing Articles
1
Etsuo Tsuchikane, Tohru Kobayashi, Motohiro Kirino, Yoshikazu Nakaoka, Satoru Otsuji, Hitone Tateyama, Hiroshi Takami, Makoto Sakurai, Nobuhisa Awata. (2000) Percutaneous myocardial ablation in double-chamber right ventricle. Catheterization and Cardiovascular Interventions 49:1, 97-101
CrossRef2
Hubert Seggewiss. (1999) Percutaneous alcohol ablation in HOCM. Catheterization and Cardiovascular Interventions 48:2, 241b-242a
CrossRef3
Ulrich Gleichmann, Hubert Seggewiß. (1998) Klinik und Therapie der hypertrophen Kardiomyopathie. Medizinische Klinik 93:4, 260-267
CrossRef
