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CLINICAL RESEARCH: HYPERTROPHIC CARDIOMYOPATHY

Comparison of Surgical Septal Myectomy and Alcohol Septal Ablation With Cardiac Magnetic Resonance Imaging in Patients With Hypertrophic Obstructive Cardiomyopathy

Uma S. Valeti, MD^_*, Rick A. Nishimura, MD^_*,_*, David R. Holmes, MD^_*, Philip A. Araoz, MD, James F. Glockner, MD, Jerome F. Breen, MD, Steve R. Ommen, MD^_*, Bernard J. Gersh, MB, ChB, DPhil^_*, A. Jamil Tajik, MD^_*, Charanjit S. Rihal, MD^_*, Hartzell V. Schaff, MD and Barry J. Maron, MD

^_* Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
Department of Radiology, Mayo Clinic, Rochester, Minnesota
Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
The Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.

Manuscript received April 10, 2006; revised manuscript received July 5, 2006, accepted August 8, 2006.

^_* Reprint requests and correspondence: Dr. Rick A. Nishimura, 200 First Street SW, Rochester, Minnesota 55905. (Email: rnishimura{at}mayo.edu).

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.

Abbreviations and Acronyms   CMR = cardiac magnetic resonance   ECG = electrocardiogram   HCM = hypertrophic cardiomyopathy   LBBB = left bundle branch block   LV = left ventricular   NYHA = New York Heart Association   RBBB = right bundle branch block

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