Alcohol Septal Ablation vs. Septal Myectomy for Obstructive HCM

Apr 25, 2022
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Authors:
Cui H, Schaff HV, Wang S, et al.
Citation:
Survival Following Alcohol Septal Ablation or Septal Myectomy for Patients With Obstructive Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2022;79:1647-1655.
Summary By:
Bina Ahmed, MD, FACC

Quick Takes

  • This was a retrospective analysis from a large cohort of patients undergoing either alcohol septal ablation or surgical myectomy for obstructive hypertrophic cardiomyopathy.
  • Alcohol septal ablation was associated with increased long-term mortality compared to septal myectomy.
  • This study was nonrandomized and the impact of residual confounding still needs to be considered.

Study Questions:

What is the long-term mortality of patients with obstructive hypertrophic cardiomyopathy (HCM) following septal myectomy or alcohol septal ablation (ASA)?

Methods:

This was a retrospective analysis from three specialty centers of all patients who underwent either septal myectomy or ASA for obstructive HCM. All-cause mortality was the primary endpoint of the study.

Results:

In the study cohort, 585 (15.2%) patients underwent ASA, and 3,274 (84.8%) underwent septal myectomy. Patients undergoing ASA were significantly older (median age, 63.0 years [IQR, 52.7-72.8 years] vs. 53.7 years [IQR, 44.9-62.8 years]; p < 0.001) and had smaller septal thickness (19.0 mm [IQR, 17.0-22.0 mm] vs. 20.0 mm [IQR, 17.0-23.0 mm]; p = 0.007). Patients undergoing ASA also had more comorbidities, including renal failure, diabetes, hypertension, and coronary artery disease. There were 4 (0.7%) early deaths in the ASA group and 9 (0.3%) in the myectomy group. Over a median follow-up of 6.4 years (IQR, 3.6-10.2 years), the 10-year all-cause mortality rate was 26.1% in the ASA group and 8.2% in the myectomy group. After adjustment for age, sex, and comorbidities, the mortality remained greater in patients having septal reduction by ASA (hazard ratio, 1.68; 95% confidence interval, 1.29-2.19; p < 0.001).

Conclusions:

In patients with obstructive HCM, ASA is associated with increased long-term all-cause mortality compared with septal myectomy. This impact on survival is independent of other known factors but may be influenced by unmeasured confounding patient characteristics.

Perspective:

The study findings suggest that ASA is associated with increased long-term mortality compared to septal myectomy for patients with HCM with obstruction. Study strengths include a large cohort of patients at experienced centers where both options for septal reduction surgery are done routinely. However, nonrandomized, retrospective analysis may have limited the ability to completely adjust for the significant differences seen in the two cohorts. There remains a need for a randomized trial to identify the correct septal reduction therapy based on patient characteristics.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Structural Heart Disease, Hypertension

Keywords: Ablation Techniques, Cardiac Surgical Procedures, Cardiology Interventions, Cardiomyopathy, Hypertrophic, Coronary Artery Disease, Diabetes Mellitus, Heart Failure, Hypertension, Renal Insufficiency, Secondary Prevention


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