Septal Myectomy After Previous Septal Artery Ablation in Hypertrophic Cardiomyopathy

Andrew W. ElBardissi, Joseph A. Dearani, Rick A. Nishimura, Steve R. Ommen, John M. Stulak, Hartzell V Schaff

Research output: Contribution to journalArticle

Abstract

OBJECTIVES To review our institution's experience with patients who failed to benefit from septal artery ablation, which necessitated subsequent septal myectomy, and to examine reasons for ablation failure and outcome of myectomy after ablation. PATIENTS AND METHODS Of 550 patients who underwent septal myectomy at Mayo Clinic Rochester between January 1, 1999, and December 31, 2006, 16 (3%) had had a total of 22 previous septal artery ablations. This subset of 16 patients was analyzed and compared with a reference group of 120 patients whose septal artery ablations were performed at our institution during this period. Angiograms obtained during septal ablation were available for 13 (81%) of 16 patients in this series and were reviewed by 2 interventional cardiologists (R.A.N. and S.R.O.). These cardiologists also reviewed preoperative and postoperative echocardiography data, hospital course, and follow-up data to compile a list of characteristics that could have contributed to failed ablation. RESULTS The median age of the patients at operation was 65 years (interquartile range [IQR], 52-72 years), and interval between ablation and myectomy was 409 days (IQR, 162-568 days). Angiograms revealed 2 failed procedures secondary to technical error. One patient had a relatively large first septal perforator with a large resting gradient. In 10 patients no septal perforators supplying the proximal septum were identified. Postoperatively, mitral regurgitation decreased from 3.00 to 1.00 (P<.001), and left ventricular outflow tract gradient decreased from 75 mm Hg to 0 mm Hg (IQR, 0-29 mm Hg; P<.001). Two patients died after surgery: 1 patient developed multiple-organ system failure on postoperative day 7, and 1 patient developed arrhythmia on postoperative day 21. Patients with previous septal artery ablation were older (P=.04), were more likely to have preoperative permanent pace-makers or implantable cardioverter-defibrillators (P=.05), were more likely to require postoperative pacemaker placement (P<.001), and had higher operative mortality (P<.001) than control patients. Fourteen patients survived the early recovery phase; 9 were followed up at a median of 1.88 years (IQR, 306 days to 3.3 years). All patients' symptoms improved. Median gradient of the left ventricular outflow tract was 13 mm Hg (IQR, 0-15 mm Hg) at follow-up with mild to moderate (1.6) mitral regurgitation. CONCLUSION Septal myectomy performed after failed ablation improves gradient and provides excellent relief of symptoms but is associated with a higher incidence of morbidity and mortality.

Original languageEnglish (US)
Pages (from-to)1516-1522
Number of pages7
JournalMayo Clinic Proceedings
Volume82
Issue number12
DOIs
StatePublished - Dec 1 2007

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Hypertrophic Cardiomyopathy
Arteries
Mitral Valve Insufficiency
Angiography
Multiple Organ Failure
Mortality
Implantable Defibrillators
Echocardiography
Cardiac Arrhythmias

Keywords

  • HCM
  • hypertrophic cardiomyopathy
  • ICD
  • implantable cardioverter-defibrillator
  • interquartile range
  • IQR
  • left ventricular outflow tract
  • LVOT
  • mitral regurgitation
  • MR
  • New York Heart Association
  • NYHA
  • permanent pacemaker
  • PPM
  • SAM
  • systolic anterior motion of the mitral valve

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Septal Myectomy After Previous Septal Artery Ablation in Hypertrophic Cardiomyopathy. / ElBardissi, Andrew W.; Dearani, Joseph A.; Nishimura, Rick A.; Ommen, Steve R.; Stulak, John M.; Schaff, Hartzell V.

In: Mayo Clinic Proceedings, Vol. 82, No. 12, 01.12.2007, p. 1516-1522.

Research output: Contribution to journalArticle

ElBardissi, AW, Dearani, JA, Nishimura, RA, Ommen, SR, Stulak, JM & Schaff, HV 2007, 'Septal Myectomy After Previous Septal Artery Ablation in Hypertrophic Cardiomyopathy', Mayo Clinic Proceedings, vol. 82, no. 12, pp. 1516-1522. https://doi.org/10.1016/S0025-6196(11)61096-3
ElBardissi, Andrew W. ; Dearani, Joseph A. ; Nishimura, Rick A. ; Ommen, Steve R. ; Stulak, John M. ; Schaff, Hartzell V. / Septal Myectomy After Previous Septal Artery Ablation in Hypertrophic Cardiomyopathy. In: Mayo Clinic Proceedings. 2007 ; Vol. 82, No. 12. pp. 1516-1522.
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abstract = "OBJECTIVES To review our institution's experience with patients who failed to benefit from septal artery ablation, which necessitated subsequent septal myectomy, and to examine reasons for ablation failure and outcome of myectomy after ablation. PATIENTS AND METHODS Of 550 patients who underwent septal myectomy at Mayo Clinic Rochester between January 1, 1999, and December 31, 2006, 16 (3{\%}) had had a total of 22 previous septal artery ablations. This subset of 16 patients was analyzed and compared with a reference group of 120 patients whose septal artery ablations were performed at our institution during this period. Angiograms obtained during septal ablation were available for 13 (81{\%}) of 16 patients in this series and were reviewed by 2 interventional cardiologists (R.A.N. and S.R.O.). These cardiologists also reviewed preoperative and postoperative echocardiography data, hospital course, and follow-up data to compile a list of characteristics that could have contributed to failed ablation. RESULTS The median age of the patients at operation was 65 years (interquartile range [IQR], 52-72 years), and interval between ablation and myectomy was 409 days (IQR, 162-568 days). Angiograms revealed 2 failed procedures secondary to technical error. One patient had a relatively large first septal perforator with a large resting gradient. In 10 patients no septal perforators supplying the proximal septum were identified. Postoperatively, mitral regurgitation decreased from 3.00 to 1.00 (P<.001), and left ventricular outflow tract gradient decreased from 75 mm Hg to 0 mm Hg (IQR, 0-29 mm Hg; P<.001). Two patients died after surgery: 1 patient developed multiple-organ system failure on postoperative day 7, and 1 patient developed arrhythmia on postoperative day 21. Patients with previous septal artery ablation were older (P=.04), were more likely to have preoperative permanent pace-makers or implantable cardioverter-defibrillators (P=.05), were more likely to require postoperative pacemaker placement (P<.001), and had higher operative mortality (P<.001) than control patients. Fourteen patients survived the early recovery phase; 9 were followed up at a median of 1.88 years (IQR, 306 days to 3.3 years). All patients' symptoms improved. Median gradient of the left ventricular outflow tract was 13 mm Hg (IQR, 0-15 mm Hg) at follow-up with mild to moderate (1.6) mitral regurgitation. CONCLUSION Septal myectomy performed after failed ablation improves gradient and provides excellent relief of symptoms but is associated with a higher incidence of morbidity and mortality.",
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T1 - Septal Myectomy After Previous Septal Artery Ablation in Hypertrophic Cardiomyopathy

AU - ElBardissi, Andrew W.

AU - Dearani, Joseph A.

AU - Nishimura, Rick A.

AU - Ommen, Steve R.

AU - Stulak, John M.

AU - Schaff, Hartzell V

PY - 2007/12/1

Y1 - 2007/12/1

N2 - OBJECTIVES To review our institution's experience with patients who failed to benefit from septal artery ablation, which necessitated subsequent septal myectomy, and to examine reasons for ablation failure and outcome of myectomy after ablation. PATIENTS AND METHODS Of 550 patients who underwent septal myectomy at Mayo Clinic Rochester between January 1, 1999, and December 31, 2006, 16 (3%) had had a total of 22 previous septal artery ablations. This subset of 16 patients was analyzed and compared with a reference group of 120 patients whose septal artery ablations were performed at our institution during this period. Angiograms obtained during septal ablation were available for 13 (81%) of 16 patients in this series and were reviewed by 2 interventional cardiologists (R.A.N. and S.R.O.). These cardiologists also reviewed preoperative and postoperative echocardiography data, hospital course, and follow-up data to compile a list of characteristics that could have contributed to failed ablation. RESULTS The median age of the patients at operation was 65 years (interquartile range [IQR], 52-72 years), and interval between ablation and myectomy was 409 days (IQR, 162-568 days). Angiograms revealed 2 failed procedures secondary to technical error. One patient had a relatively large first septal perforator with a large resting gradient. In 10 patients no septal perforators supplying the proximal septum were identified. Postoperatively, mitral regurgitation decreased from 3.00 to 1.00 (P<.001), and left ventricular outflow tract gradient decreased from 75 mm Hg to 0 mm Hg (IQR, 0-29 mm Hg; P<.001). Two patients died after surgery: 1 patient developed multiple-organ system failure on postoperative day 7, and 1 patient developed arrhythmia on postoperative day 21. Patients with previous septal artery ablation were older (P=.04), were more likely to have preoperative permanent pace-makers or implantable cardioverter-defibrillators (P=.05), were more likely to require postoperative pacemaker placement (P<.001), and had higher operative mortality (P<.001) than control patients. Fourteen patients survived the early recovery phase; 9 were followed up at a median of 1.88 years (IQR, 306 days to 3.3 years). All patients' symptoms improved. Median gradient of the left ventricular outflow tract was 13 mm Hg (IQR, 0-15 mm Hg) at follow-up with mild to moderate (1.6) mitral regurgitation. CONCLUSION Septal myectomy performed after failed ablation improves gradient and provides excellent relief of symptoms but is associated with a higher incidence of morbidity and mortality.

AB - OBJECTIVES To review our institution's experience with patients who failed to benefit from septal artery ablation, which necessitated subsequent septal myectomy, and to examine reasons for ablation failure and outcome of myectomy after ablation. PATIENTS AND METHODS Of 550 patients who underwent septal myectomy at Mayo Clinic Rochester between January 1, 1999, and December 31, 2006, 16 (3%) had had a total of 22 previous septal artery ablations. This subset of 16 patients was analyzed and compared with a reference group of 120 patients whose septal artery ablations were performed at our institution during this period. Angiograms obtained during septal ablation were available for 13 (81%) of 16 patients in this series and were reviewed by 2 interventional cardiologists (R.A.N. and S.R.O.). These cardiologists also reviewed preoperative and postoperative echocardiography data, hospital course, and follow-up data to compile a list of characteristics that could have contributed to failed ablation. RESULTS The median age of the patients at operation was 65 years (interquartile range [IQR], 52-72 years), and interval between ablation and myectomy was 409 days (IQR, 162-568 days). Angiograms revealed 2 failed procedures secondary to technical error. One patient had a relatively large first septal perforator with a large resting gradient. In 10 patients no septal perforators supplying the proximal septum were identified. Postoperatively, mitral regurgitation decreased from 3.00 to 1.00 (P<.001), and left ventricular outflow tract gradient decreased from 75 mm Hg to 0 mm Hg (IQR, 0-29 mm Hg; P<.001). Two patients died after surgery: 1 patient developed multiple-organ system failure on postoperative day 7, and 1 patient developed arrhythmia on postoperative day 21. Patients with previous septal artery ablation were older (P=.04), were more likely to have preoperative permanent pace-makers or implantable cardioverter-defibrillators (P=.05), were more likely to require postoperative pacemaker placement (P<.001), and had higher operative mortality (P<.001) than control patients. Fourteen patients survived the early recovery phase; 9 were followed up at a median of 1.88 years (IQR, 306 days to 3.3 years). All patients' symptoms improved. Median gradient of the left ventricular outflow tract was 13 mm Hg (IQR, 0-15 mm Hg) at follow-up with mild to moderate (1.6) mitral regurgitation. CONCLUSION Septal myectomy performed after failed ablation improves gradient and provides excellent relief of symptoms but is associated with a higher incidence of morbidity and mortality.

KW - HCM

KW - hypertrophic cardiomyopathy

KW - ICD

KW - implantable cardioverter-defibrillator

KW - interquartile range

KW - IQR

KW - left ventricular outflow tract

KW - LVOT

KW - mitral regurgitation

KW - MR

KW - New York Heart Association

KW - NYHA

KW - permanent pacemaker

KW - PPM

KW - SAM

KW - systolic anterior motion of the mitral valve

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