View
1
Download
0
Category
Preview:
Citation preview
CP1288794-1
The 2014 Mayo Approach
to the Management of HCM
and Non-Compaction
R A Nishimura MD MACC MACP
Judd and Mary Morris Leighton Professor
Mayo Clinic
No disclosures or conflict of interest
CP1288794-2
Let’s start with a case
52 y/o man – Class III DOE
Loud murmur – 300 mg lopressor
Gradient 100 mmHg
CP1288794-3
Next step?
1. More meds
2. Dual chamber PM
3. Septal ablation
4. Septal myectomy
5. AICD
CP1288794-4
Treatment of HCM
Relieve
Symptoms
Prevent
Sudden Death
Dynamic
LVO Obstruction
CP1288794-5
Gradient
LAP
Relieve obstruction Improve diastolic filling
Reduce MR
Improve symptoms
CP1288794-6
Beta Blockers
Ca Blockers
Disopyramide
Intolerant
Intolerant
Continued
symptoms
Myectomy
DDD pacing
Ablation
Hypertrophic Cardiomyopathy
Medical therapy : symptomatic pt
CP1288794-7 CP980117-19
NSR PACE
Dual Chamber Pacing
CP1288794-8
“New medicines and
other cures always work
miracles for awhile…”
William
Heberden
1877
CP1288794-9
Hypertrophic Cardiomyopathy
Dual chamber pacing – update 2014
Placebo effect – wears out 6 months
Overall improvement
< 30% patients
Possible detrimental effect
Long-term pacing : myocardial dysfunction
Mayo data
CP1288794-10
Septal Reduction Therapy
CP1288794-11
Septal Reduction Therapy
Septal
Myectomy
CP1288794-12
Operative mortality 0.8%
Gradient 3 mm
Post-op NYHA 1-2 94%
Surgical septal myectomy for symptomatic HOCM is safe
and effective
In the hands of experienced surgeons
CP1288794-13
0
20
40
60
80
100
Before Postop
I-II
III-IV%
Pts
Septal Myectomy: Mayo Data
256 pts – F/U 10 yrs
CP1288794-14 CP1160937-13
Myectomy and Survival
Overall survival
Years Ommen et al: JACC, 2005
Same results for cardiac survival and sudden death P<0.001
0.5
0.6
0.7
0.8
0.9
1.0
0 2 4 6 8 10
Nonobstructive
Nonoperated obstructive
Myectomy (Mayo)
CP1288794-15
Hypertrophic Cardiomyopathy
It is clear that surgical myectomy will result in marked
long-lasting symptomatic improvement in over 90% of
patients with severe symptoms and obstruction
CP1288794-16
Septal
Ablation
The “New Kid
on the Block”
A localized heart attack
CP1288794-17
Septal Ablation
CP1288794-18 CP980117-28
Hypertrophic Cardiomyopathy
Baseline After ablation
0 mm Hg
150 mm Hg
0 mm Hg
150 mm Hg
CP1288794-19
“Surgery now has no role in the
management of HCM…”
“Ablation is the new gold standard for
the 21st century”
“Myectomy is only an impediment to
the development of alcohol ablation”
Heart 2006:92:1339
JACC 2004:44:2054
Br J Card 2006:13:58
CP1288794-20
Septal
Ablation
Structural
Anatomy Anatomy
Coronaries
Success rate
CP1288794-21
Fixed subaortic stenosis
8-10% of referrals
No Systolic Anterior
Motion of Mitral Valve
Ablation
ineffective
CP1288794-22
Flail leaflet
7-8%
MR jet directed
anteriorly
Ablation
ineffective
CP1288794-23
Septal
Ablation
Structural
Anatomy Anatomy
Coronaries
Success
CP1288794-24
Septal perfusion: just right
CP1288794-25
Septal perfusion: too much
CP1288794-26
Septal perfusion: ??????
CP1288794-27
Septal Ablation
There are a subgroup of patients in whom the
“targeted septum” cannot be reached by septal
perforators
CP1288794-28
Septal myectomy
Pre Post
CP1288794-29
Septal ablation
Pre Post
CP1288794-30
Septal
Ablation
Short
Term Follow-up
Complicatons
CP1288794-31
Complete Heart Block
(10-18%)
CP1288794-32
Ventricular Fibrillation
Incidence unknown
Sudden unexpected
CP1288794-33
Septal Ablation
Other acute complications
Coronary dissection: 0-2.5% (1.8%)
Large infarction: ????
Tamponade: .8-5% (3%)
Stroke: 1.1% Nagueh JACC 2001
Faber EJE 2004
Fernandez JACC CV Int 2008
Firoozi EHJ 2002
Qin JACC 2001
Ralph-Edwards JTCVS 2005
Alam J int C 2006
Baggish Heart 2006
CP1288794-34
This needs to be done in
an experienced center !!!!
25 y/o
Ablation done
Now on
transplant list
CP1288794-35
Septal
Ablation
Clinical
Outcome
CP1288794-36
0
20
40
60
80
100
0 1 2 3 4
CP1286515-6
Survival without Severe Sx
Pts aged <65 yrs
No. at risk
Myectomy 72 69 61 50
Ablation 52 37 24 18
Follow-up (yrs) Sorajja et al, Circ 2008
Myectomy
Ablation
p=0.02
71%
90%
CP1288794-37
Septal Ablation
4 yr survival free of death, NYHA Class III/IV or myectomy : 76%
1 of 4 will not have benefit
CP1288794-38
Ablation Myectomy
Younger
Healthy
Long life-span
Active
Elderly
Co-morbidities
Limited life-span
Sedentary
CP1288794-39
0
50
100
150
200
250
MyectomyAblation
Pa
tie
nts
/ye
ar
1973 1978 1983 1988 1993 1998 2003 2008 2013
Year
Septal Reduction Therapy
Mayo Clinic
CP1288794-40
Treatment of HCM
Relieve
Symptoms
Prevent
Sudden Death
CP1288794-41
Can we identify
those patients at
risk for sudden
death?
CP1288794-42
Risk Factors for Sudden Death
Arrest
Sustained VT
FH HCM and Sudden death
LVH > 30 mm
Unexplained syncope NSVT
BP drop TMET
Gadolinium DE
LVO
CAD
Really Bad
Somewhat Bad
Bad
CP1288794-43
AICD: Caveats
•72 y/o with four episodes syncope over 5 years
•18 y/o with one episode syncope 1 week ago
CP1288794-44
Let’s finish with a case
54 y/o woman
Atypical chest pain
Normal exam LV RV
CP1288794-45
What would you do?
1. Right and left heart cath / bx
2. Observation only
3. AICD
4. Anticoagulation
5. Surgery
CP1288794-46
Noncompaction of the myocardium
A failure of the normal embryologic
development of the heart
Myocardium – “noncompacted”
(ratio 2:1 of trabeculated to solid)
Early studies
High rate of sudden death, stroke, etc
CP1288794-47
Benign Malignant
Noncompaction Wide spectrum of prognosis
Systolic function
Symptoms
Family history
CP1288794-48
Noncompaction Wide spectrum of prognosis
AICD
Anticoagulation
Observe
Reassure
Benign Malignant
CP1288794-49
The 2014 Mayo Approach
to the Management of HCM
and Non-Compaction
R A Nishimura MD MACC MACP
Judd and Mary Morris Leighton Professor
Mayo Clinic
No disclosures or conflict of interest
Recommended