1. Septal ablation in Hypertrophic Cardiomyopathy Charles Knight London Chest Hospital Advanced Angioplasty 2003

2. Terminology Non-surgical septal reduction (NSSR) Percutaneous transluminal septal myocardial ablation (PTSMA) Transcoronary ablation of septal hypertrophy (TASH) Septal ablation Alcohol ablation HOCM ablation Sigwart procedure

3. History 1980’s Preliminary experiments by Ulrich Sigwart at Laussane Temporary balloon occlusion of first septal artery Injection of verapamil down first septal artery June 1994 First septal ablation by Ulrich Sigwart at Royal Brompton 1997 Described as ‘profoundly aggressive’ with an ‘unacceptably high mortality and morbidity’ in NEJM* *NEJM 1997;337:349

4. Myotomy-myectomy

5. Patient selection No evidence for effect on prognosis Majority of patients with HCM have no obstruction (~75%) Majority of patients with obstruction have symptoms responsive to medical therapy Those with obstruction and unresponsive symptoms can be treated with septal ablation or myotomy-myectomy

6. No effect on: Underlying pathology –Myocardial disarray –Small coronary artery abnormalities –Diastolic dysfunction Associated mitral valve abnormalities Risk of sudden death Prognosis Effect on: Outflow tract gradient Symptoms

7. Procedure Temporary pacing wire Intermediate wire to S1 OTW balloon inflated at origin of S1 Wire removed, balloon inflated 3-5ml of absolute alcohol injected 5 minutes marination then balloon deflated

9. Septal Ablation - Published Reports Knight et al Circulation 1997;95:207518 patients Faber et al Circulation 1998;98:241591 patients Lakkis et al Circulation1998;98:175033 patients Gietzen et al Eur Heart J 1999;20:134250 patients Kim et al Am J Cardiol 1999;83:122020 patients Qin et al J Am Coll Cardiol 2001;38:199425 patients Total237 patients Gietzen et al Eur Heart J 1999;20:134237 patients Faber et al Heart 2000;83:32625 patients Firoozi et al Eur Heart J 2002;23:161720 patients Shamin et al NEJM 2002 ;347:132664 patients Total146 patients Longer term (7-36 month follow-up)

10. Pre Post

11. Effect on Outflow Gradient All reports: –65 mmHg pre –5 mmHg post Reduction in gradient sustained in long-term Shamin et al N Engl J Med 2002;347:1326

12. Effect on Symptoms All reports show significant improvement –Mean NYHA class pre 2.85, post 1.3 Maintained over longer-term

13. Effect on exercise 3 reports assessed peak O 2 consumption (n=104) –44% improvement 7 reports assessed exercise duration/watts (n=204) –41% improvement Maintained at longer- term Shamin et al N Engl J Med 2002;347:1326

14. Mortality Short-term: 5/303 deaths (1.7%) –2 in patients with severe pulmonary disease –1 pulmonary embolus (line-related DVT) –1 sudden AV block day 4 –1 sudden out-of hospital (?AV block) Long-term: 1 further death (pancreatic carcinoma)

15. Heart-Block Overall rate is ~ 20% requiring PPM Ranges from 0-40% Incidence appears to be reducing (contrast echo) 10% of surgical patients require PPM Beneficial effects of procedure similar in paced/not paced patients* *Shamin et al N Engl J Med 2002;347:1326

16. Arrhythmias Early VF in 1.6% No late arrhythmias reported

17. Late Ventricular Dilatation Information from 134 patients (4 reports) 4.2mm Pre 4.7mm Post Shamin et al N Engl J Med 2002;347:1326

18. Comparison with Surgery No randomised studies Two recent non-randomised comparisons –St George’s Hospital –Cleveland Clinic Patients well matched but septal ablation patients older and more co-morbidity

19. Cleveland ClinicSt. George’s Qin et al JACC 2001;38:1994 Firoozi et al Eur Heart J 2002;23:1617

20. Conclusions Still limited data Not profoundly aggressive Results similar to surgery Mortality and morbidity acceptable and similar to surgery Should be performed as part of a HCM service by experienced operators Patient selection of paramount importance