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Circulation. 2019;140:11–12. DOI: 10.1161/CIRCULATIONAHA.119.039889 July 2, 2019 11
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Sigwart Therapeutic Infarct for HOCM
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July 2, 2019 Circulation. 2019;140:11–12. DOI: 10.1161/CIRCULATIONAH...
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Therapeutic myocardial infarction

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It took another 10 years, after a positive response of a different Review Board,before the first alcohol septal ablation (ASA) could be performed at the Royal Brompton Hospital in London 25 years ago.1
The very first patient, after having been informed in great length and meticulous detail about all possible risks,agreed to an experimental procedure, the outcome of which could not be defined.
She had severe left ventricular hypertrophy that created an impressive and highly
symptomatic outflow tract gradient despite pacing and drug treatment; after the ablation on June 18, 1994, she remained asymptomatic for >20 years.

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Therapeutic myocardial infarction

  1. 1. Circulation. 2019;140:11–12. DOI: 10.1161/CIRCULATIONAHA.119.039889 July 2, 2019 11 The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. Key Words:  ablation techniques ◼ cardiomyopathy, hypertrophic ◼ left ventricular outflow obstruction Ulrich Sigwart, MD T he answer to this question was a clear no when I put it to the local Institu- tional Review Board 35 years ago. My request was based on the observation that a brief angioplasty balloon inflation inside the first major septal branch of the left anterior descending coronary artery in symptomatic patients with hy- pertrophic obstructive cardiomyopathy (HOCM) resulted in immediate reduction of the left ventricular outflow tract gradient. It took another 10 years, after a positive response of a different Review Board, before the first alcohol septal ablation (ASA) could be performed at the Royal Brompton Hospital in London 25 years ago.1 The very first patient, after hav- ing been informed in great length and meticulous detail about all possible risks, agreed to an experimental procedure, the outcome of which could not be defined. She had severe left ventricular hypertrophy that created an impressive and highly symptomatic outflow tract gradient despite pacing and drug treatment; after the ablation on June 18, 1994, she remained asymptomatic for 20 years. Since then the procedure has been performed throughout the world in many thousands of patients with HOCM resistant to medical treatment, but the dis- cussion, whether such alternative to surgical myectomy is appropriate, carries on among cardiologists and cardiac surgeons. Surgery for HOCM, a logical and straightforward procedure, was pioneered by Cleland more than half a century ago at the same hospital where the first ASA was done. Surgical myectomy has a proven track record; 90% of patients return to work and follow a normal lifestyle.2 The excision by knife of the muscular obstacle to left ventricular ejection results in immediate gradient reduction or even elimina- tion. However, the published data on surgical myectomy have been collected at high volume centers, which may not be accessible to a large portion of patients. Moreover, there is an important psychological threshold for patients to accept an open-heart procedure with all its inherent discomfort and extended hospital stay. Not surprisingly, the majority of patients prefer the nonsurgical solution.3 It did not take long after the introduction of such intervention light to create fierce scepticism. The heated debate about the safety and efficiency of ASA is ongoing. For the opponents of the procedure, the danger of creating a substrate for dangerous arrhythmias remains an important issue. A substantial number of clinicians and researchers keep evoking the likelihood of sudden death as a result of iatrogenic myocardial infarction.2 Also, the possibility of injury to the intramyo- cardial conduction system should not be underestimated, as outlined in numerous publications, including the American and European guidelines.4,5 Unfortunately, the septal conduction system cannot be localized by today’s technologies in vivo, but from anatomic studies we know about the proximity to septal arterial supply. Right bundle-branch block is common after ASA and it is no secret that, for the time being, we must live with a higher incidence of com- © 2019 American Heart Association, Inc. PERSPECTIVE Therapeutic Myocardial Infarction for Hypertrophic Obstructive Cardiomyopathy Is It Appropriate? Circulation https://www.ahajournals.org/journal/circ Downloadedfromhttp://ahajournals.orgbyonJuly4,2019
  2. 2. Sigwart Therapeutic Infarct for HOCM FRAMEOFREFERENCE July 2, 2019 Circulation. 2019;140:11–12. DOI: 10.1161/CIRCULATIONAHA.119.03988912 plete heart block after catheter-based procedures in ­comparison with surgical septal reduction. In large se- ries, up to 15% of ASA procedures will require implan- tation of a pacemaker. The risk is significantly higher in the presence of preexisting left bundle-branch block. This complication occurs clearly less frequently after surgical myectomy. Does the implantation of a pacemaker pose a ma- jor problem? There is certainly a cost issue, because the implantation of a device increases the price of an otherwise less expensive intervention. But even under such circumstances, the final bill will still not reach the level of the surgical treatment cost. Also, in high-risk patients, the device can be adapted to cover the risk of ventricular tachycardia or fibrillation and allows con- tinuous monitoring of numerous parameters. In some cases, right ventricular apical pacing can improve left ventricular outflow tract hemodynamics. How about long-term follow-up? As of today, there are numerous studies evaluating symptoms and survival of patients undergoing ASA or surgery for HOCM. Even the most recent publications could not find a signifi- cant difference: the long-term survival rate after either procedure was 90%, and the pacemaker implantation rate for ASA did not exceed 15%. One issue with catheter-based procedures remains the ease of access: ASA appears so simple that any car- diologist with angioplasty experience may feel compe- tent to do it. This is definitely not the case. Experience with selecting the appropriate vessel to achieve the best result is crucial. Echocardiographic monitoring of the target vessel distribution is mandatory. Sometimes un- orthodox approaches are required, including diagonal or even right coronary branches for injection. Although there may be hesitation by many physicians to refer HOCM patients to centers with large experience, such referrals would not only benefit patients, but also help clarify the contemporary role of septal ablation. To date, no randomized study comparing surgical with catheter-based septal reduction has been per- formed. In my view, the time has come to perform such a trial at institutions with high expertise in both techniques. Recruitment may present a major obstacle, but high-volume centers may have sufficient numbers of patients suitable for both procedures. Such an en- deavor would probably be the only way to pacify the disagreement between the 2 camps and allow a sound statement on the appropriateness of ASA. Until such evidence is available, we must live with some degree of uncertainty as to the indication for therapeutic myocardial infarction for HOCM, and re- member that the preference of the patient should al- ways be considered. ARTICLE INFORMATION Correspondence Ulrich Sigwart, MD, FACC, EFESC, FRCP, 1, av. de Miremont, CH-1206 Geneva, Switzerland. Email ulrich.sigwart@unige.ch Affiliation Professor Emeritus, University of Geneva, Switzerland. Disclosures None. REFERENCES 1. Sigwart U. Non-surgical myocardial reduction for hypertrophic obstructive cardiomyopathy. Lancet. 1995;346:211–214. 2. Maron BJ. Surgery for hypertrophic obstructive cardiomyopa- thy: alive and quite well. Circulation. 2005;111:2016–2018. doi: 10.1161/01.CIR.0000164396.80300.1A 3. Fifer MA. Septal reduction therapy for hypertrophic obstruc- tive cardiomyopathy. J Am Coll Cardiol. 2018;72:3095–3097. doi: 10.1016/j.jacc.2018.10.013 4. Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy. Circulation 2011; 24:e783– 831. doi: 10.1161/CIR.0b013e318223e2bd 5. Elliott PM, Anastakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, Hagege AA, Lafont A, Limongelli G, Mahrholdt H, McKenna WJ, Mogensen J, Nihoyannopoulos P, Nistri S, Pieper PG, Pieske B, Rapezzi C, Rutten FH, Tillmanns C, Watkins H. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy. Eur Heart J. 2014; 35:2733–2779. Downloadedfromhttp://ahajournals.orgbyonJuly4,2019

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