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Cardiac Hypertrophy, Heart Failure and Cardiomyopathy
Published in Mary N. Sheppard, Practical Cardiovascular Pathology, 2022
Percutaneous transluminal septal myocardial ablation, otherwise known as alcohol septal ablation was introduced in 1990s as an alternative septal reduction therapy at a time when the operative mortality from septal myectomy was much higher than it is today. The procedure is minimally invasive and is performed via the same approach as cardiac catheterization and coronary angiography, with injection of ethanol into the first or second septal perforator of the left anterior descending artery. Ethanol induces an iatrogenic myocardial infarction in the distribution of the basal septum and results in long-term remodelling to abolish obstruction of the LVOT. Since its introduction, this has become an increasingly popular option for septal reduction therapy, such that the number of ablations performed in the last decade exceeds the number of myectomies done in the last half century. There has been concern regarding the arrhythmogenic potential due to the iatrogenic infarction that encompasses approximately 10% of the left ventricular mass following septal ablation and intraprocedural and postprocedural rates of complete heart block have been as high as 20%, with the need for permanent pacemaker implantation.
Complications of Septal Myectomy
Published in Srilakshmi M. Adhyapak, V. Rao Parachuri, Hypertrophic Cardiomyopathy, 2020
Lawrence M. Wei, Charlotte Spear, Vinay Badhwar
Septal myectomy is the primary surgical therapy for the management of hypertrophic cardiomyopathy (HCM) with obstruction. Following Brock’s description in 1957 of the obstructive nature of HCM [1], surgeons soon recognized that the underlying anatomical abnormality favored a surgical solution. By 1961, Kirklin and Ellis [2], as well as Morrow and Brockenbrough [3], had established the technique of subaortic resection of the muscular ventricular septum and described the original technique of removing a narrow bar of septal myocardium. The operation has since been refined methodically to include a wider and more apically directed resection and now commonly is described as extended septal myectomy (Figure 9.1).
Syncope
Published in Stanley R. Resor, Henn Kutt, The Medical Treatment of Epilepsy, 2020
Douglas L. Wood, Bernard J. Gersh
Patients with hypertrophic obstructive cardiomyopathy who experience syncope related to left ventricular outflow obstruction will experience relief of their symptoms when appropriate medical therapy using calcium channel blockers and/or beta blockers is instituted. Some patients may benefit from septal myectomy, however, such therapy has not been convincingly shown to reduce the risk of sudden death in patients who have been found to have either spontaneous or inducible sustained ventricular tachycardia or ventricular fibrillation. These patients are best treated with either amiodarone or implantable defibrillators.
Current and emerging pharmacotherapy for the management of hypertrophic cardiomyopathy
Published in Expert Opinion on Pharmacotherapy, 2023
Akiva Rosenzveig, Neil Garg, Shiavax J. Rao, Amreen K. Kanwal, Arjun Kanwal, Wilbert S. Aronow, Matthew W. Martinez
Pharmacologic management of obstructive HCM has been exclusive to beta-blockers, calcium channel blockers, and disopyramide. However, these pharmacotherapies have lacked evidence of large randomized clinical trials. For patients who were refractory to the medications and with New York Heart Association (NYHA) Class III-IV symptoms, septal reduction therapy (SRT) became an option in the 1960s. Septal myectomy was first introduced by Morrow and Braunwald at the National Institutes of Health (NIH) [9]. Septal myectomy was effective at relieving the obstruction to flow and now is one of the safer open-heart operations with a mortality rate of 0.4% at experienced clinical centers [10]. More recently, alcohol septal ablation (ASA) has been established as a less invasive alternative with a comparable mortality rate of 0.6% at experienced centers [11].
Multi-modality management of hypertrophic cardiomyopathy
Published in Hospital Practice, 2023
Shiavax J. Rao, Shaikh B. Iqbal, Arjun S. Kanwal, Wilbert S. Aronow, Srihari S. Naidu
In their retrospective study, Kim et al. established that the 4862 patients who underwent ASA in the US between 2003 and 2011 had less than 1% mortality rate at 30 days post procedure in high-volume centers. However, there was no difference in outcomes between high- and low-volume centers [37]. Periprocedural complications and hospital stay are lower in ASA compared to septal myectomy (SM) [38–40]. Survival estimates at 1 and 10 years are 98% and 77–81% respectively [34,41]. Reintervention was seen in 10.1–13% of patients, mostly within the first year [40–42]. Few patients experienced early post-procedural ventricular arrhythmia. Comparative studies between septal myectomy and ASA have demonstrated no significant difference in all‐cause mortality, cardiovascular mortality, or sudden cardiac death rate [42]. The reduction of LV outflow gradient is the most important therapeutic benefit affecting long-term survival [42].
Early, Single Center Experience with Ozaki Technique for Aortic Valve Reconstruction
Published in Structural Heart, 2020
Alberto Albertini, Eliana Raviola, Simone Calvi, Alberto Tripodi, Paola Quagliara, Fabio Zucchetta, Elisa Mikus
Results: The mean age was 52.95 ± 14.72 years old (21–74 years, 76.2% male). The predominant pathology was aortic valve stenosis (61.9%) followed by aortic regurgitation (33.3%) and one patient was treated for endocarditis (4.7%). Nine patients (42.8%) presented with a bicuspid aortic valve and in one patient a monocuspid valve was found. Concomitant procedures included: coronary arteries by-pass grafts (5 patients, 23.8%), ascending aorta replacement (1 patient, 4.7%), mitral valve valvuloplasty (5 patients, 23.8%), interventricular septal myectomy (1 patient, 4.7%). The mean aortic cross-clamp time and cardiopulmonary bypass time were respectively 131.95 and 119.57 minutes. All patients have been extubated (mean intubation time 9.76 ± 4.99 hours) and intensive care unit and hospital stay was respectively 2.5 ± 1.25 and 6.10 ± 4.68 days. There was no in-hospital mortality. Transthoracic echocardiography showed a peak aortic pressure gradient of 14.09 ± 7.62 mmHg and a mean aortic pressure gradient of 7.91 ± 3.33 mmHg. Aortic valve regurgitation was trivial in 8 patients (38%) and no valve stenosis was detected.