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J Am Coll Cardiol, 2007; 50:795-798, doi:10.1016/j.jacc.2007.04.065 (Published online 6 August 2007). © 2007 by the American College of Cardiology Foundation

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CLINICAL RESEARCH: CARDIOMYOPATHY

Outcome of Surgical Myectomy After Unsuccessful Alcohol Septal Ablation for the Treatment of Patients With Hypertrophic Obstructive Cardiomyopathy

Sherif F. Nagueh, MD, FACC^_*,_*, John M. Buergler, MD, FACC^_*, Miguel A. Quinones, MD, FACC^_*, William H. Spencer, III, MD, FACC and Gerald M. Lawrie, MD, FACC^_*

^_* Methodist DeBakey Heart Center and Department of Cardiology, Methodist Hospital, Houston, Texas
Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina.

Manuscript received January 5, 2007; revised manuscript received April 9, 2007, accepted April 10, 2007.

^_* Reprint requests and correspondence: Dr. Sherif F. Nagueh, 6550 Fannin Street, SM-667, Houston, Texas 77030-2717. (Email: snagueh{at}tmh.tmc.edu).

Objectives: We sought to determine the outcome of myectomy after unsuccessful alcohol ablation.

Background: Alcohol septal ablation results in symptomatic improvement and a reduction in dynamic obstruction in most hypertrophic obstructive cardiomyopathy patients. However, a few patients remain with severe symptoms and obstruction and need surgery. The outcome of these cases is not well known.

Methods: The medical records of 375 patients who underwent alcohol ablation at our institution were reviewed. Twenty patients (5.3%, mean age 53 ± 18 years, 17 women) subsequently needed surgical myectomy. The New York Heart Association (NYHA) functional class, angina class, exercise duration, left ventricular outflow tract (LVOT) gradient, ejection fraction, and septal thickness were tabulated. The anatomy and distribution of the septal perforator arteries were examined.

Results: After ablation, NYHA functional class (3 to 2.5; p < 0.05) and LVOT gradient (93 ± 23 mm Hg to 71 ± 26 mm Hg; p < 0.05) were slightly improved, without a change in exercise duration (171 ± 124 s to 168 ± 148 s; p > 0.5). Myectomy was performed at 19 ± 15 months after ablation. There was no operative mortality, but permanent pacing was needed in 2 patients after surgery, and 3 other cases needed pacing before, or as a complication of, alcohol ablation. A significant improvement was noted, with the NYHA functional class decreasing to 1, exercise duration increasing to 423 ± 171 s, and LVOT gradient decreasing to 6 ± 11 mm Hg (all p < 0.05 versus post-alcohol ablation).

Conclusions: Myectomy can be successfully performed after failed alcohol ablation, but with a higher incidence of heart block than in cases where only surgery is performed. Otherwise, alcohol ablation does not appear to adversely affect surgical outcome.

Abbreviations and Acronyms   AV = atrioventricular   CK = creatine kinase   EF = ejection fraction   HOCM = hypertrophic obstructive cardiomyopathy   LV = left ventricle/ventricular   LVEF = left ventricular ejection fraction   LVOT = left ventricular outflow tract   MCE = myocardial contrast echocardiography

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