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Long-Term Outcomes After Septal Reduction in Obstructive HCM
Quick Takes
- In a retrospective, multicenter cohort study of 1,832 obstructive HCM patients who underwent septal reduction therapy (SRT) at HCM centers of excellence, 30-day survival after SRT was 0.4%, with a 5% risk for complications and 4% risk for pacemakers.
- SRT was associated with clinical improvement in 91% at 1 year and 88% were alive at 7 years.
- Over the long-term, 13% developed HF in 5 years, with older age at time of intervention and female sex predicting HF risk.
Study Questions:
What are the long-term outcomes after septal reduction therapy (SRT) and predictors of adverse events after SRT in patients with obstructive hypertrophic cardiomyopathy (HCM)?
Methods:
The SHARE (Sarcomeric Human Cardiomyopathy Registry) consortium is a longitudinal registry of HCM patients at 13 high-volume, international expert HCM centers. Obstruction was defined as a peak gradient of >30 mm Hg at rest or >50 mm Hg with provocation. The authors assessed periprocedural outcomes within 30 days, improvement in New York Heart Association (NYHA) class at 1 year, rest and provoked left ventricular outflow tract (LVOT) gradient <50 mm Hg at 1 year, and need for repeat procedures. Long-term outcomes included death or composite of cardiac transplant, need for LV assist device (LVAD), ejection fraction (EF) <35%, new NYHA class III or IV symptoms, or major ventricular arrhythmias (VAs).
Results:
This study included 3,566 patients with obstructive HCM and 1,832 (51%) of these patients underwent SRT at a mean age of 51 years. The SRT included alcohol septal ablation (ASA) in 25%, with the rest receiving septal myectomy. ASA was performed in older patients with a greater symptom burden, compared to patients receiving septal myectomy. A median of 25 SRTs were performed in adults per center. Observed 30-day mortality was low at 0.4%, with a 30-day complication rate of 5%; 4% needed a pacemaker, with the majority receiving it after ASA. Improvement in NYHA class 1 year after SRT was noted in 91% of cases. After a median of 7 years after SRT, 88% of patients were alive. Mortality did not change over time across different centers. Repeat SRT was performed in 6% of patients usually after ASA. Over a median of 5 years, 13% had heart failure (HF), including 2% who needed an LVAD and 15% a heart transplant. Drop in LVEF was noted in 12% over a median of 6.4 years. Atrial fibrillation (AF) was noted in 21%, 4 years after SRT, and this was associated with a higher incidence of HF. VAs were noted in 5% of patients after SRT and no independent predictors were identified. The only predictor of HCM-related death after SRT was older age at the time of procedure. Predictors of HF after SRT included older age at procedure and female sex.
Conclusions:
The authors report that in a retrospective, multicenter registry, SRT in obstructive HCM patients at high-volume centers was safe with an associated 30-day mortality of <1% and clinically beneficial, with 91% noting improved symptoms at 1 year. Over the long-term, 13% developed HF, with older age at time of intervention and female sex predicting HF risk.
Perspective:
With the advent of myosin inhibitors, treatment options for obstructive HCM have expanded. Patients now have to choose between myosin inhibitors versus SRTs. However, data on effectiveness and adverse events with SRT are limited to single-center studies with short-term data. This study provides data from a multicenter, international consortium across 13 HCM centers of excellence. These data suggest SRT at high-volume centers is associated with a low 30-day mortality, high effectiveness at 1 year, and an 88% survival rate at 7 years. HF after SRT was noted in 13% of patients, with 21% also developing AF and 5% VAs. Importantly, older age at treatment and female sex were associated with higher risk for developing HF after SRT. These data suggest earlier consideration for gradient reduction therapy in women with obstructive HCM.
Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Heart Failure and Cardiomyopathies
Keywords: Ablation, Arrhythmias, Cardiac, Hypertrophic Cardiomyopathy
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