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Charanjit S Rihal - One of the best experts on this subject based on the ideXlab platform.
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Alcohol Septal Ablation to prevent left ventricular outflow tract obstruction during transcatheter mitral valve replacement first in man study
Jacc-cardiovascular Interventions, 2019Co-Authors: Dee Dee Wang, Igor F Palacios, Michael A Fifer, Mayra Guerrero, Marvin H Eng, Mackram F Eleid, Christopher Meduri, Vivek Rajagopal, Pradeep K Yadav, Charanjit S RihalAbstract:Abstract Objectives This study evaluates outcomes of pre-emptive Alcohol Septal Ablation (ASA) to prevent iatrogenic left ventricular outflow tract (LVOT) obstruction after transcatheter mitral valve replacement (TMVR). Background LVOT obstruction is a life-threatening complication of TMVR. Bail-out ASA has been described as a therapeutic option for patients with outflow obstruction during TMVR, but little is known about pre-emptive ASA. Methods Multicenter registry of patients with severe mitral valve disease who underwent pre-emptive ASA to mitigate LVOT obstruction risk after TMVR. High risk of LVOT obstruction was predicted in all patients by pre-procedural computed tomographic imaging. Results Thirty patients (age 76.1 ± 7.7 years; women 76.7%) with severe mitral valve disease underwent pre-emptive ASA to mitigate TMVR-induced LVOT obstruction risk. Twenty patients underwent mitral valve replacement (14 transSeptal, 3 transatrial, 1 transapical, 1 transSeptal with percutaneous laceration of anterior mitral leaflet, 1 treated with surgical mitral valve replacement). Eight patients experienced clinical improvement post-ASA. Two patients died before TMVR. Median increase in neo-LVOT surface area post-ASA was 111.2 mm2 (interquartile range: 71.4 to 193.1 mm2). Five patients (16.7%) required pacemaker implantation post-ASA. In-hospital and 30-day mortality post-ASA was 6.7% (2/30 patients). After ASA, TMVR was performed successfully in 100% of attempted cases. In-hospital and 30-day mortality post-TMVR was 5.3% (1/19). Mortality of entire cohort was 10% (3/30 patients: 2 post-ASA before TMVR, 1 died 30 days post-TMVR). Conclusions Pre-emptive ASA is associated with a significant increase in predicted neo-LVOT area before TMVR and may enable safe TMVR in patients usually excluded secondary to prohibitive risk of LVOT obstruction.
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predictors of an optimal clinical outcome with Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy
Catheterization and Cardiovascular Interventions, 2013Co-Authors: Paul Sorajja, David R Holmes, Charanjit S Rihal, Bernard J Gersh, Rick A Nishimura, Josepha Binder, John F Bresnahan, Steve R OmmenAbstract:Background Alcohol Septal Ablation has emerged as a therapy for patients with obstructive hypertrophic cardiomyopathy (HCM). However, there are limited data on the predictors of success with the procedure. Methods We examined patient characteristics and cardiac morphology as well as procedural data on 166 HCM patients (mean age, 63 years; 43% men), who underwent Ablation at Mayo Clinic. Patients were contacted to determine vital status and symptoms to assess the primary endpoint of survival free of death and severe symptoms (New York Heart Association, class III or IV dyspnea). Results The strongest patient characteristics that predicted clinical success were older age, less severe left ventricular outflow tract gradient, lesser ventricular Septal hypertrophy, and a smaller left anterior descending (LAD) diameter. Mitral valve geometry or ventricular Septal morphology did not predict outcome. Patients with ≥3 characteristics (age ≥65 years, gradient 50 patients was an independent predictor of survival free of severe symptoms. The volume of Alcohol injected, number of arteries injected, or size of Septal perforator artery were not predictive of clinical success. Conclusions Greater case volume and selection for key patient and anatomic characteristics are associated with superior outcomes with Alcohol Septal Ablation. © 2012 Wiley Periodicals, Inc.
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survival after Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy
Circulation, 2012Co-Authors: Paul Sorajja, Steve R Ommen, David R Holmes, Joseph A Dearani, Charanjit S Rihal, Bernard J Gersh, Ryan J Lennon, Rick A NishimuraAbstract:Background—The clinical efficacy of Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy (HCM) has been demonstrated, but the long-term effects of the procedure remain uncertain. This study examined the survival of patients after Septal Ablation performed in a tertiary HCM referral center. Methods and Results—We examined 177 patients (mean age, 64 years; 68% women) who underwent Septal Ablation at our institution. Over a follow-up of 5.7 years, survival free of all mortality was no different than the expected survival for a comparable general population, and similar to that of age- and sex-matched patients who underwent isolated surgical myectomy (8-year survival estimate, 79% versus 79%; P=0.64). For the end point of documented sudden cardiac death or unknown cause of death, the incidence per 100 person-year follow-up was 1.31 (95% confidence interval, 0.60–2.38). Residual left ventricular outflow tract gradient after Ablation was an independent predictor of long-term survival free of any ...
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outcome of Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy
Circulation, 2008Co-Authors: Paul Sorajja, Steve R Ommen, Charanjit S Rihal, Bernard J Gersh, Rick A Nishimura, Hartzell V Schaff, Uma S Valeti, David O Hodge, David R HolmesAbstract:Background— The clinical efficacy of Alcohol Septal Ablation for drug-refractory hypertrophic cardiomyopathy remains unclear. This study examines the outcome of Alcohol Septal Ablation performed at a tertiary hypertrophic cardiomyopathy referral center. Methods and Results— Among 601 patients with severely symptomatic obstructive hypertrophic cardiomyopathy referred for Alcohol Septal Ablation or myectomy from 1998 to 2006, 138 patients (median age, 64 years; 39% men) chose to undergo Ablation. Procedural complications included death in 1.4%, sustained ventricular arrhythmias in 3%, tamponade in 3%, and pacemaker implantation in 20%. This rate was higher than a combined complication rate of 5% in age- and gender-matched patients who had undergone Septal myectomy at Mayo Clinic (P<0.0001). Four-year survival free of all mortality was 88.0% (95% confidence interval, 79.4 to 97.5%), which was similar to that of the age- and gender-matched patients who had undergone myectomy (P=0.18). Six patients had documen...
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comparison of surgical Septal myectomy and Alcohol Septal Ablation with cardiac magnetic resonance imaging in patients with hypertrophic obstructive cardiomyopathy
Journal of the American College of Cardiology, 2007Co-Authors: Uma S Valeti, Steve R Ommen, David R Holmes, Bernard J Gersh, Rick A Nishimura, Philip A Araoz, James F Glockner, Jerome F Breen, Jamil A Tajik, Charanjit S RihalAbstract:Objectives This study sought to describe the acute morphologic differences that result from Septal myectomy and Alcohol Septal Ablation using cardiac magnetic resonance (CMR) imaging. Background Surgical Septal myectomy and Alcohol Septal Ablation relieve left ventricular outflow tract obstruction in severely symptomatic patients with hypertrophic cardiomyopathy (HCM). Methods Cine and contrast-enhanced CMR images were obtained in HCM patients before and after Septal myectomy (n = 24) and Alcohol Septal Ablation (n = 24). Location of Septal reduction, extent of myocardial necrosis, and conduction system abnormalities with each technique were compared. Results With Septal myectomy, there was a discrete area of resected tissue consistently localized to anterior septum. In contrast, Alcohol Septal Ablation resulted in a more variable effect. In most patients, Alcohol Septal Ablation caused a transmural region of tissue necrosis, located more inferiorly in the basal septum than myectomy and usually extending into the right ventricular side of the septum at the midventricular level. However, there were 6 patients after Alcohol Septal Ablation in whom there was sparing of the basal septum with residual gradients at follow-up. After the procedure, left bundle branch block developed in 46% of Septal myectomy patients, and right bundle branch block was evident in 58% of Alcohol Septal Ablation patients. Conclusions Septal myectomy and Alcohol Septal Ablation for severely symptomatic, drug-refractory patients with obstructive HCM have different morphologic effects and location sites on left ventricular Septal myocardium. Septal myectomy provides consistent resection of the obstructing portion of the anterior basal septum, whereas the effect of ethanol Septal Ablation is more variable. These findings may have important implications for patient selection and management as well as long-term outcome.
Rick A Nishimura - One of the best experts on this subject based on the ideXlab platform.
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temporal occurrence of arrhythmic complications after Alcohol Septal Ablation
Circulation-cardiovascular Interventions, 2020Co-Authors: Bassim Elsabawi, Rick A Nishimura, Jeffrey B Geske, Gregory W Barsness, Yong Mei Cha, Mackram F EleidAbstract:Background: The temporal occurrence of arrhythmic complications after Alcohol Septal Ablation (ASA) is unclear. As a result, the appropriate time to monitor patients after ASA is controversial. The...
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surgical myectomy versus Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy a propensity score matched cohort
The Journal of Thoracic and Cardiovascular Surgery, 2019Co-Authors: Anita Nguyen, Joseph A Dearani, Rick A Nishimura, Hartzell V Schaff, Dustin Hang, Jeffrey B Geske, Brian D Lahr, Steve R OmmenAbstract:Abstract Objectives In patients with hypertrophic cardiomyopathy, obstruction of the left ventricular outflow tract can be relieved by surgical Septal myectomy or Alcohol Septal Ablation, but uncertainty remains regarding long-term results and comparative effectiveness of Alcohol Septal Ablation. This study aims to compare short- and long-term outcomes of the 2 procedures. Methods Between December 1998 and September 2016, 2407 patients underwent Septal myectomy and 211 patients underwent Alcohol Septal Ablation at our institution. After 2:1 propensity score matching, the study cohort included 334 patients who underwent myectomy and 167 patients who underwent Alcohol Septal Ablation. Results Median (interquartile range) ages of patients in the myectomy and Alcohol Septal Ablation groups were 65 (58-71) years and 64 (56-73) years ( P = .9), respectively. After intervention, median resting left ventricular outflow tract gradient at predischarge transthoracic echocardiography was 0 (0-10) mm Hg in the myectomy group (n = 288) and 21 (10-60) mm Hg in the Alcohol Septal Ablation group (n = 63) ( P P = .1). Survival of patients undergoing Septal myectomy was better than that of an age-, sex-, and race-matched US population (82% vs 75% at 12 years, P = .01). Reintervention for left ventricular outflow tract obstruction was more likely to occur in patients who received Alcohol Septal Ablation (hazard ratio, 33.3; 95% confidence interval, 4.4-250.6; P Conclusions There were no differences in survival of patients undergoing myectomy or Alcohol Septal Ablation, but freedom from reintervention and early and late reduction of left ventricular outflow tract gradient are superior in patients undergoing Septal myectomy.
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surgical Septal myectomy versus Alcohol Septal Ablation assessing the status of the controversy in 2014
Circulation, 2014Co-Authors: Barry J Maron, Rick A NishimuraAbstract:In hypertrophic cardiomyopathy (HCM), left ventricular (LV) outflow tract obstruction, caused by mitral valve systolic anterior motion (SAM) with elevated intracavitary LV pressures, can produce disabling symptoms of heart failure and excess cardiovascular mortality.1–7 Outflow gradients are common in HCM, present in 70% of patients at rest or with physiological exercise4 (Figure 1). Fifty years ago, early HCM investigators recognized the importance of obliterating LV outflow obstruction (and mitral regurgitation) and restoring normal hemodynamics, initially with the Septal myectomy operation advanced by Dr Andrew Morrow at the National Institutes of Health.6,7 However, HCM has not been immune to controversy, and through the years, several debates have focused on the significance of dynamic outflow obstruction and its treatment.7 The most recent of these conversations concerns the most effective strategy for reducing gradient and symptoms, triggered by the introduction of catheter-based percutaneous Alcohol Septal Ablation (ASA) as an alternative to myectomy.8–19 Figure 1. Treatment algorithm for hypertrophic cardiomyopathy (HCM) patients with heart failure symptoms of exertional dyspnea with or without chest pain. LVOT indicates left ventricular outflow tract; and NYHA, New York Heart Association. The nonsurgical technique, introduced by Professor Ulrich Sigwart at the Royal Brompton Hospital in 1994,8 involves injection of 1 to 4 mL of 96% ethanol into the first Septal perforator branch of the left anterior descending coronary artery to produce a basal Septal myocardial infarction and ultimately remodeling of the LV outflow tract. ASA avoids the recovery time with loss of work, residual discomfort, and anxiety associated with surgery. It was soon enthusiastically embraced and heavily promoted by many clinicians and interventional cardiologists, initially in Europe, thereby expanding the treatment armamentarium of HCM and triggering a polarized and sometimes contentious debate within the cardiovascular community. Indeed, many related …
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predictors of an optimal clinical outcome with Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy
Catheterization and Cardiovascular Interventions, 2013Co-Authors: Paul Sorajja, David R Holmes, Charanjit S Rihal, Bernard J Gersh, Rick A Nishimura, Josepha Binder, John F Bresnahan, Steve R OmmenAbstract:Background Alcohol Septal Ablation has emerged as a therapy for patients with obstructive hypertrophic cardiomyopathy (HCM). However, there are limited data on the predictors of success with the procedure. Methods We examined patient characteristics and cardiac morphology as well as procedural data on 166 HCM patients (mean age, 63 years; 43% men), who underwent Ablation at Mayo Clinic. Patients were contacted to determine vital status and symptoms to assess the primary endpoint of survival free of death and severe symptoms (New York Heart Association, class III or IV dyspnea). Results The strongest patient characteristics that predicted clinical success were older age, less severe left ventricular outflow tract gradient, lesser ventricular Septal hypertrophy, and a smaller left anterior descending (LAD) diameter. Mitral valve geometry or ventricular Septal morphology did not predict outcome. Patients with ≥3 characteristics (age ≥65 years, gradient 50 patients was an independent predictor of survival free of severe symptoms. The volume of Alcohol injected, number of arteries injected, or size of Septal perforator artery were not predictive of clinical success. Conclusions Greater case volume and selection for key patient and anatomic characteristics are associated with superior outcomes with Alcohol Septal Ablation. © 2012 Wiley Periodicals, Inc.
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survival after Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy
Circulation, 2012Co-Authors: Paul Sorajja, Steve R Ommen, David R Holmes, Joseph A Dearani, Charanjit S Rihal, Bernard J Gersh, Ryan J Lennon, Rick A NishimuraAbstract:Background—The clinical efficacy of Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy (HCM) has been demonstrated, but the long-term effects of the procedure remain uncertain. This study examined the survival of patients after Septal Ablation performed in a tertiary HCM referral center. Methods and Results—We examined 177 patients (mean age, 64 years; 68% women) who underwent Septal Ablation at our institution. Over a follow-up of 5.7 years, survival free of all mortality was no different than the expected survival for a comparable general population, and similar to that of age- and sex-matched patients who underwent isolated surgical myectomy (8-year survival estimate, 79% versus 79%; P=0.64). For the end point of documented sudden cardiac death or unknown cause of death, the incidence per 100 person-year follow-up was 1.31 (95% confidence interval, 0.60–2.38). Residual left ventricular outflow tract gradient after Ablation was an independent predictor of long-term survival free of any ...
Steve R Ommen - One of the best experts on this subject based on the ideXlab platform.
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surgical myectomy versus Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy a propensity score matched cohort
The Journal of Thoracic and Cardiovascular Surgery, 2019Co-Authors: Anita Nguyen, Joseph A Dearani, Rick A Nishimura, Hartzell V Schaff, Dustin Hang, Jeffrey B Geske, Brian D Lahr, Steve R OmmenAbstract:Abstract Objectives In patients with hypertrophic cardiomyopathy, obstruction of the left ventricular outflow tract can be relieved by surgical Septal myectomy or Alcohol Septal Ablation, but uncertainty remains regarding long-term results and comparative effectiveness of Alcohol Septal Ablation. This study aims to compare short- and long-term outcomes of the 2 procedures. Methods Between December 1998 and September 2016, 2407 patients underwent Septal myectomy and 211 patients underwent Alcohol Septal Ablation at our institution. After 2:1 propensity score matching, the study cohort included 334 patients who underwent myectomy and 167 patients who underwent Alcohol Septal Ablation. Results Median (interquartile range) ages of patients in the myectomy and Alcohol Septal Ablation groups were 65 (58-71) years and 64 (56-73) years ( P = .9), respectively. After intervention, median resting left ventricular outflow tract gradient at predischarge transthoracic echocardiography was 0 (0-10) mm Hg in the myectomy group (n = 288) and 21 (10-60) mm Hg in the Alcohol Septal Ablation group (n = 63) ( P P = .1). Survival of patients undergoing Septal myectomy was better than that of an age-, sex-, and race-matched US population (82% vs 75% at 12 years, P = .01). Reintervention for left ventricular outflow tract obstruction was more likely to occur in patients who received Alcohol Septal Ablation (hazard ratio, 33.3; 95% confidence interval, 4.4-250.6; P Conclusions There were no differences in survival of patients undergoing myectomy or Alcohol Septal Ablation, but freedom from reintervention and early and late reduction of left ventricular outflow tract gradient are superior in patients undergoing Septal myectomy.
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predictors of an optimal clinical outcome with Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy
Catheterization and Cardiovascular Interventions, 2013Co-Authors: Paul Sorajja, David R Holmes, Charanjit S Rihal, Bernard J Gersh, Rick A Nishimura, Josepha Binder, John F Bresnahan, Steve R OmmenAbstract:Background Alcohol Septal Ablation has emerged as a therapy for patients with obstructive hypertrophic cardiomyopathy (HCM). However, there are limited data on the predictors of success with the procedure. Methods We examined patient characteristics and cardiac morphology as well as procedural data on 166 HCM patients (mean age, 63 years; 43% men), who underwent Ablation at Mayo Clinic. Patients were contacted to determine vital status and symptoms to assess the primary endpoint of survival free of death and severe symptoms (New York Heart Association, class III or IV dyspnea). Results The strongest patient characteristics that predicted clinical success were older age, less severe left ventricular outflow tract gradient, lesser ventricular Septal hypertrophy, and a smaller left anterior descending (LAD) diameter. Mitral valve geometry or ventricular Septal morphology did not predict outcome. Patients with ≥3 characteristics (age ≥65 years, gradient 50 patients was an independent predictor of survival free of severe symptoms. The volume of Alcohol injected, number of arteries injected, or size of Septal perforator artery were not predictive of clinical success. Conclusions Greater case volume and selection for key patient and anatomic characteristics are associated with superior outcomes with Alcohol Septal Ablation. © 2012 Wiley Periodicals, Inc.
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survival after Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy
Circulation, 2012Co-Authors: Paul Sorajja, Steve R Ommen, David R Holmes, Joseph A Dearani, Charanjit S Rihal, Bernard J Gersh, Ryan J Lennon, Rick A NishimuraAbstract:Background—The clinical efficacy of Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy (HCM) has been demonstrated, but the long-term effects of the procedure remain uncertain. This study examined the survival of patients after Septal Ablation performed in a tertiary HCM referral center. Methods and Results—We examined 177 patients (mean age, 64 years; 68% women) who underwent Septal Ablation at our institution. Over a follow-up of 5.7 years, survival free of all mortality was no different than the expected survival for a comparable general population, and similar to that of age- and sex-matched patients who underwent isolated surgical myectomy (8-year survival estimate, 79% versus 79%; P=0.64). For the end point of documented sudden cardiac death or unknown cause of death, the incidence per 100 person-year follow-up was 1.31 (95% confidence interval, 0.60–2.38). Residual left ventricular outflow tract gradient after Ablation was an independent predictor of long-term survival free of any ...
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outcome of Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy
Circulation, 2008Co-Authors: Paul Sorajja, Steve R Ommen, Charanjit S Rihal, Bernard J Gersh, Rick A Nishimura, Hartzell V Schaff, Uma S Valeti, David O Hodge, David R HolmesAbstract:Background— The clinical efficacy of Alcohol Septal Ablation for drug-refractory hypertrophic cardiomyopathy remains unclear. This study examines the outcome of Alcohol Septal Ablation performed at a tertiary hypertrophic cardiomyopathy referral center. Methods and Results— Among 601 patients with severely symptomatic obstructive hypertrophic cardiomyopathy referred for Alcohol Septal Ablation or myectomy from 1998 to 2006, 138 patients (median age, 64 years; 39% men) chose to undergo Ablation. Procedural complications included death in 1.4%, sustained ventricular arrhythmias in 3%, tamponade in 3%, and pacemaker implantation in 20%. This rate was higher than a combined complication rate of 5% in age- and gender-matched patients who had undergone Septal myectomy at Mayo Clinic (P<0.0001). Four-year survival free of all mortality was 88.0% (95% confidence interval, 79.4 to 97.5%), which was similar to that of the age- and gender-matched patients who had undergone myectomy (P=0.18). Six patients had documen...
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surgical myectomy versus Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy will there ever be a randomized trial
Journal of the American College of Cardiology, 2007Co-Authors: I Olivotto, Martin S Maron, Franco Cecchi, Steve R Ommen, Barry J MaronAbstract:Dynamic left ventricular outflow tract obstruction is an important pathophysiologic feature of hypertrophic cardiomyopathy (HCM) and a predictor of clinical deterioration and cardiovascular mortality. Patients with marked obstruction and severe limiting symptoms refractory to maximum medical management are considered candidates for invasive Septal reduction therapy, which includes surgical myectomy and Alcohol Septal Ablation (ASA). Availability of both surgical myectomy and ASA has polarized the cardiovascular community concerning the most appropriate implementation of these two interventions. The ensuing controversy of whether myectomy and ASA are truly equivalent options has resulted in calls for a prospective randomized trial. However, upon analysis, such a myectomy versus ASA trial, adequately powered to compare the key issue of long-term outcome, poses a myriad of practical problems that seem virtually insurmountable. Therefore, it is appropriate to revisit this evolving debate at this time, identify the unique obstacles to a randomized study design, and achieve some clarity concerning the most realistic clinical strategies for symptomatic patients with HCM and outflow obstruction.
Michael A Fifer - One of the best experts on this subject based on the ideXlab platform.
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Alcohol Septal Ablation to prevent left ventricular outflow tract obstruction during transcatheter mitral valve replacement first in man study
Jacc-cardiovascular Interventions, 2019Co-Authors: Dee Dee Wang, Igor F Palacios, Michael A Fifer, Mayra Guerrero, Marvin H Eng, Mackram F Eleid, Christopher Meduri, Vivek Rajagopal, Pradeep K Yadav, Charanjit S RihalAbstract:Abstract Objectives This study evaluates outcomes of pre-emptive Alcohol Septal Ablation (ASA) to prevent iatrogenic left ventricular outflow tract (LVOT) obstruction after transcatheter mitral valve replacement (TMVR). Background LVOT obstruction is a life-threatening complication of TMVR. Bail-out ASA has been described as a therapeutic option for patients with outflow obstruction during TMVR, but little is known about pre-emptive ASA. Methods Multicenter registry of patients with severe mitral valve disease who underwent pre-emptive ASA to mitigate LVOT obstruction risk after TMVR. High risk of LVOT obstruction was predicted in all patients by pre-procedural computed tomographic imaging. Results Thirty patients (age 76.1 ± 7.7 years; women 76.7%) with severe mitral valve disease underwent pre-emptive ASA to mitigate TMVR-induced LVOT obstruction risk. Twenty patients underwent mitral valve replacement (14 transSeptal, 3 transatrial, 1 transapical, 1 transSeptal with percutaneous laceration of anterior mitral leaflet, 1 treated with surgical mitral valve replacement). Eight patients experienced clinical improvement post-ASA. Two patients died before TMVR. Median increase in neo-LVOT surface area post-ASA was 111.2 mm2 (interquartile range: 71.4 to 193.1 mm2). Five patients (16.7%) required pacemaker implantation post-ASA. In-hospital and 30-day mortality post-ASA was 6.7% (2/30 patients). After ASA, TMVR was performed successfully in 100% of attempted cases. In-hospital and 30-day mortality post-TMVR was 5.3% (1/19). Mortality of entire cohort was 10% (3/30 patients: 2 post-ASA before TMVR, 1 died 30 days post-TMVR). Conclusions Pre-emptive ASA is associated with a significant increase in predicted neo-LVOT area before TMVR and may enable safe TMVR in patients usually excluded secondary to prohibitive risk of LVOT obstruction.
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hypertrophic obstructive cardiomyopathy Alcohol Septal Ablation
European Heart Journal, 2011Co-Authors: Michael A Fifer, Ulrich SigwartAbstract:Alcohol Septal Ablation (ASA) was introduced in 1994 as an alternative to Septal myectomy for patients with hypertrophic obstructive cardiomyopathy and symptoms refractory to medical therapy. This procedure alleviates symptoms by producing a targeted, limited infarction of the upper interventricular septum, resulting in an increase in left ventricular outflow tract (LVOT) diameter, a decrease in LVOT gradient, and regression of the component of LV hypertrophy that is due to pressure overload. Clinical success, with improvement in symptoms and reduction in gradient, is achieved in the great majority of patients with either resting or provocable LVOT obstruction. The principal morbidity of the procedure is complete heart block, resulting in some patients in the requirement for a permanent pacemaker. The introduction of myocardial contrast echocardiography as a component of the ASA procedure has contributed to the induction of smaller myocardial infarctions with lower dosages of Alcohol and, in turn, fewer complications. Non-randomized comparisons of Septal Ablation and Septal myectomy have shown similar mortality rates and post–procedure New York Heart Association class for the two procedures.
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ventricular arrhythmia following Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy
American Journal of Cardiology, 2009Co-Authors: Peter A Noseworthy, Igor F Palacios, Michael H Picard, Gus J Vlahakes, Patricia A Lowry, Michael A Fifer, Michael A Rosenberg, Jeremy N Ruskin, Danita M Sanborn, Theofanie MelaAbstract:We sought to assess the risk of sudden cardiac death (SCD) and ventricular arrhythmia after Alcohol Septal Ablation (ASA) for obstructive hypertrophic cardiomyopathy. ASA is a nonsurgical alternative to Septal myectomy for treatment of symptomatic, drug-refractory, obstructive hypertrophic cardiomyopathy. The effect of ASA on ventricular arrhythmia risk is not well established. We examined the rates of SCD among 89 patients treated with ASA. The secondary end point was ventricular tachycardia/ventricular fibrillation (VT/VF), appropriate implantable cardioverter defibrillator (ICD) therapy, or cardiac arrest after ASA among those with implanted ICDs or permanent pacemakers (n = 42). Patients were classified as either high-risk or low-risk on the basis of established clinical indications for ICD implantation. No mortality was attributable to SCD at a mean follow-up of 5.0 ± 2.3 years in the entire cohort. Among the 42 patients with an ICD or permanent pacemaker, 9 had documented VT/VF, cardiac arrest, or appropriate ICD therapy, resulting in an annual event rate of 4.9%/year. The annual event rate for VT/VF, cardiac arrest, or appropriate ICD therapy was 2.8%/year (4 of 29 patients) in low-risk patients and 13.4% in high-risk patients (5 of 13 patients). A 10-mm Hg increase in the immediate post-ASA gradient was associated with a hazard ratio of 2.66 for arrhythmic events (95% confidence interval 1.55 to 4.56, p
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sustained improvement in left ventricular diastolic function after Alcohol Septal Ablation for hypertrophic obstructive cardiomyopathy
European Heart Journal, 2006Co-Authors: Davinder S Jassal, Igor F Palacios, Michael H Picard, Gus J Vlahakes, Patricia A Lowry, Michael A Fifer, Tomas G Neilan, Danita M YoergerAbstract:Aims Impaired diastolic function is responsible for many of the clinical features of hypertrophic cardiomyopathy. In patients with hypertrophic obstructive cardiomyopathy (HOCM) whose symptoms are refractory to medical therapy, Alcohol Septal Ablation (ASA) reduces left ventricular (LV) outflow tract gradient, with short-term improvement in LV diastolic function. Little is known about the longer term impact of ASA on diastolic function. Methods and results We evaluated LV diastolic function at baseline and 1- and 2-year follow-up after successful ASA. In 30 patients (58±15 years, 22 men) who underwent successful ASA, New York Heart Association class was lower at 1-year follow-up compared with baseline (3.0±0.5 to 1.5±0.7; P <0.0001). LV outflow tract gradient (76±37 to 19±12; P <0.0001), interventricular Septal thickness (19±2 to 14±2; P <0.0001), and left atrial volume (26±5 to 20±4; P <0.0001) were decreased. Significant improvement in E-wave deceleration time, isovolumic relaxation time, early diastolic mitral lateral annular velocity ( E ′), mitral inflow propagation velocity ( V p), ratio of transmitral early LV filling velocity ( E ) to early diastolic Doppler tissue imaging of the mitral annulus ( E / E ′), and E / V p were observed at 1 year following successful ASA. These changes persisted in the subset cohort ( n =21) for whom 2-year data were available. Conclusion Successful ASA for HOCM leads to significant and sustained improvement in echocardiographic measures of diastolic function, which may contribute to improved functional status after successful ASA.
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time course of pressure gradient response after first Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy
American Journal of Cardiology, 2006Co-Authors: Danita M Yoerger, Igor F Palacios, Michael H Picard, Gus J Vlahakes, Patricia A Lowry, Michael A FiferAbstract:Alcohol Septal Ablation (ASA) causes remodeling of the upper septum and left ventricular outflow tract (LVOT) and reduction in the LVOT gradient. The time course of gradient reduction early after ASA has not been established. This study characterized the time course of gradient response early after ASA. Patients underwent clinical assessment and transthoracic echocardiography at baseline and immediately, 3 days, 3 months, and 1 year after ASA. Forty-seven patients underwent ASA. The baseline LVOT gradient was 98 ± 48 mm Hg. Three-month echocardiographic success, defined as ≥50% gradient reduction from baseline, was achieved in 41 procedures (87%); thus, there were 6 failures. On the basis of percentage reduction in LVOT gradient at 3 days, 2 distinct subgroups of the success group were identified. These were monophasic success (≥50% gradient reduction at 3 days and 3 months, n = 25) and triphasic success (<50% gradient reduction at 3 days but ≥50% gradient reduction at 3 months, n = 16). LVOT gradient in the triphasic success group was similar to that in the failure group at 3 days (81 ± 28 vs 99 ± 31 mm Hg, p = NS) but similar to that of the monophasic success group at 3 months (24 ± 20 vs 12 ± 16 mm Hg, p = NS) and at 1 year (27 ± 24 vs 13 ± 20 mm Hg, p = NS). In conclusion, many patients who undergo ultimately successful ASA demonstrate triphasic LVOT gradient response patterns, with a large gradient 3 days after the procedure.
Josef Veselka - One of the best experts on this subject based on the ideXlab platform.
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Clinical Study Comparison of Long-Term Effect of Dual-Chamber Pacing and Alcohol Septal Ablation in Patients with Hypertrophic Obstructive Cardiomyopathy
2020Co-Authors: Jan Krejci, David Zemanek, Pavel Gregor, Klaudia Vyskocilova, Karol Curila, Radka Stepanova, Miroslav Novak, Ladislav Groch, Josef VeselkaAbstract:Introduction. Nonpharmacological treatment of patients with hypertrophic obstructive cardiomyopathy (HOCM) comprises surgical myectomy (SME), Alcohol Septal Ablation (ASA), and dual-chamber (DDD) pacing. The aim of the study was to compare the long-term effect of DDD pacing and ASA in symptomatic HOCM patients. Patients and Methods. We evaluated retrospective data from three cardiocenters; there were 24 patients treated with DDD pacing included and 52 treated with ASA followed for 101 ± 49 and 87 ± 23 months, respectively. Results. In the group treated with DDD pacing, the left ventricle outflow tract gradient (LVOTG) decreased from 82 ± 44 mmHg to 21 ± 21 mmHg, and NYHA class improved from 2.7 ± 0.5 to 2.1 ± 0.6 (both < 0.001). In the ASA-treated group, a decline in LVOTG from 73 ± 38 mmHg to 24 ± 26 mmHg and reduction in NYHA class from 2.8 ± 0.5 to 1.7 ± 0.8 were observed (both < 0.001). The LVOTG change was similar in both groups ( = 0.264), and symptoms were more affected by ASA ( = 0.001). Conclusion. ASA and DDD pacing were similarly effective in reducing LVOTG. The symptoms improvement was more expressed in patients treated with ASA
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University Hospital Motol, 2nd Medical Sch…
2016Co-Authors: See Profile, Josef VeselkaAbstract:Long-term survival after Alcohol Septal Ablation for hypertrophic obstructive cardiomyopathy: A comparison with general populatio
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CLINICAL RESEARCH
2016Co-Authors: Josef VeselkaAbstract:Long-term survival after Alcohol Septal Ablation for hypertrophic obstructive cardiomyopathy: a comparison with general populatio
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long term clinical outcome after Alcohol Septal Ablation for obstructive hypertrophic cardiomyopathy results from the euro asa registry
European Heart Journal, 2016Co-Authors: Josef Veselka, Max Liebregts, Morten K Jensen, Jaroslav Januska, Jan Krejci, Peter Riis Hansen, Thomas Bartel, Maciej Dabrowski, Vibeke Marie Almaas, Hubert SeggewissAbstract:Aims The first cases of Alcohol Septal Ablation (ASA) for obstructive hypertrophic cardiomyopathy (HCM) were published two decades ago. Although the outcomes of single-centre and national ASA registries have been published, the long-term survival and clinical outcome of the procedure are still debated. Methods and results We report long-term outcomes from the as yet largest multinational ASA registry (the Euro-ASA registry). A total of 1275 (58 ± 14 years, median follow-up 5.7 years) highly symptomatic patients treated with ASA were included. The 30-day post-ASA mortality was 1%. Overall, 171 (13%) patients died during follow-up, corresponding to a post-ASA all-cause mortality rate of 2.42 deaths per 100 patient-years. Survival rates at 1, 5, and 10 years after ASA were 98% (95% CI 96–98%), 89% (95% CI 87–91%), and 77% (95% CI 73–80%), respectively. In multivariable analysis, independent predictors of all-cause mortality were age at ASA ( P < 0.01), septum thickness before ASA ( P < 0.01), NYHA class before ASA ( P = 0.047), and the left ventricular (LV) outflow tract gradient at the last clinical check-up ( P = 0.048). Alcohol Septal Ablation reduced the LV outflow tract gradient from 67 ± 36 to 16 ± 21 mmHg ( P < 0.01) and NYHA class from 2.9 ± 0.5 to 1.6 ± 0.7 ( P < 0.01). At the last check-up, 89% of patients reported dyspnoea of NYHA class ≤2, which was independently associated with LV outflow tract gradient ( P < 0.01). Conclusions The Euro-ASA registry demonstrated low peri-procedural and long-term mortality after ASA. This intervention provided durable relief of symptoms and a reduction of LV outflow tract obstruction in selected and highly symptomatic patients with obstructive HCM. As the post-procedural obstruction seems to be associated with both worse functional status and prognosis, optimal therapy should be focused on the elimination of LV outflow tract gradient.
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twenty years of Alcohol Septal Ablation document more than a history of a single interventional procedure
Cor et vasa, 2015Co-Authors: Josef VeselkaAbstract:Abstract The first Alcohol Septal Ablation (ASA) was performed in 1994. The concept of “therapeutic acute myocardial infarction” caused by application of concentrated Alcohol into coronary artery is not quite unique since certain arrhythmias were treated in a similar way in the past; however, ASA has been discussed widely since its introduction and refused for many years by many cardiologists. Sufficiently robust data from long-term follow-up of patients with hypertrophic obstructive cardiomyopathy treated with ASA were obtained in the past few years only, demonstrating the safety and long-term efficacy of ASA. This article deals with a history of the above-mentioned interventional procedure, its indications, technical aspects, safety, and long-term results.