Percutaneous alcohol septal ablation for hypertrophic obstructive cardiomyopathy: Technical review and long-term clinical and echocardiographic outcomes | Revista Portuguesa de Cardiologia (English edition)

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"identificador" => "aff0010" ] ] ] 9 => array:3 [ "nombre" => "José Luís" "apellidos" => "López-Sendón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidade de Intervenção Cardiovascular, Serviço de Cardiologia, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cardiologia Intervencionista, Servicio de Cardiologia, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Ablação septal alcoólica percutânea na cardiomiopatia hipertrófica obstrutiva: revisão da técnica e resultados clínicos e ecocardiográficos a longo-prazo" ] ] 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First, the anatomy of the heart is presented and the target septal area is identified (A). Injection of echocardiographic contrast into the target septal branch opacifies the basal part of the septum, verifying the optimal choice of septal branch (B). A more sustained opacification of the basal septum after alcohol injection signifies a good alcohol depot (C)." ] ] ] "textoCompleto" => "IntroductionHypertrophic obstructive cardiomyopathy (HOCM), first described in the late 1950s, is now recognized to be a primary autosomal dominant myocardial disorder characterized by a dynamic narrowing of the left ventricular outflow tract (LVOT), secondary to asymmetrical septal hypertrophy and systolic anterior motion of the mitral valve. The consequent reduction in cardiac output is responsible for the typical symptoms of dyspnea, angina pectoris and stress-induced syncope, with increased risk for sudden cardiac death in some patients.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Treatment of patients with symptomatic HOCM aims to reduce functional disability and the extent of outflow tract obstruction and to improve diastolic filling and survival in a disease with a mortality rate estimated at 3–4% per year.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Administration of negatively inotropic drugs is the treatment of first choice, and succeeds in improving functional capacity and symptoms in a high percentage of patients. However, 5–10% of patients with marked LVOT obstruction have severe symptoms unresponsive to medical therapy.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Such patients have traditionally been referred for surgical myectomy of the basal septum, which has been the gold standard treatment for decades. This procedure relieves left ventricular (LV) outflow obstruction, providing long-term symptomatic and outcome improvement in most patients, with a mortality of 1–2% in experienced centers.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Percutaneous alcohol septal ablation (ASA) has emerged as a novel interventional treatment option during the last decade.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> This technique, in which ethanol is injected into one or more septal perforator branches of the left anterior descending coronary artery, achieves a circumscribed infarction of the area supplied by the occluded septal branch, reducing the hypertrophied interventricular septum with consequent expansion of LVOT area and gradient reduction.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> The acute and long-term efficacy of ASA has been proven, with hemodynamic results resembling those of myectomy.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a>The aim of the present study was to evaluate the acute and long-term clinical and echocardiographic outcome of patients with symptomatic HOCM treated by percutaneous ASA in our center.MethodsStudy populationThe study included 14 consecutive patients with HOCM who underwent ASA between 1999 and 2010 at the Interventional Cardiology Unit of Hospital La Paz, Madrid, Spain.The diagnosis of HOCM was based on typical clinical, electrocardiographic, and echocardiographic features, with ventricular myocardial hypertrophy occurring in the absence of any other cardiac or systemic cause. The magnitude of myocardial hypertrophy was assessed by M-mode and two-dimensional transthoracic echocardiography, using standard techniques.Eligibility criteria for ASA were: (1) persistent severe symptoms, defined as New York Heart Association (NYHA) class III or IV dyspnea and/or Canadian Cardiovascular Society (CCS) class III or IV angina, despite optimized medical treatment; (2) dynamic LVOT obstruction (peak gradient >50mmHg at rest or provocable) caused by systolic anterior motion of the mitral valve; (3) ventricular septal thickness ≥15 mm; (4) absence of significant intrinsic mitral valve disease; and (5) absence of need for concomitant cardiac surgical procedure (such as bypass grafting or valve replacement). All patients gave written informed consent for the procedure.Percutaneous alcohol septal ablation procedureASA procedures started by obtaining arterial and venous femoral accesses, using the standard Judkins technique, followed by placement of a 6F temporary transvenous pacemaker lead in the right ventricular apex, a 5F pigtail or multipurpose catheter into the LV, and a 6F or 7F guiding catheter in the ascending aorta. Re-evaluation of the patient's hemodynamics and re-measurement of the intracavitary gradient were then performed and continuously monitored throughout the procedure, through simultaneous pressure measurement in the LV and the aorta. Physiologic provocation of the gradient was assessed with the Valsalva maneuver and checking for the Brockenbrough-Braunwald-Morrow sign by inducing a premature ventricular complex.Coronary angiography was then performed to exclude severe coronary disease and to locate the first septal perforator artery. A 0.014-in. guidewire was advanced to engage, in most cases, the first septal branch of the left anterior descending artery (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A). A slightly oversized, short (∼10mm), over-the-wire angioplasty balloon was then introduced into the septal perforator artery, using standard methods; the lumen of this device provides the route for selective delivery of angiographic contrast, echo contrast, and ultimately alcohol, into the septal artery. After careful fluoroscopic positioning of the balloon (using selective angiography to exclude encroachment onto the LAD), it was inflated and the guidewire removed (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>A small amount of angiographic contrast was then injected through the balloon lumen to ensure that there was no spill-back into the LAD or collateral recruitment (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C). The balloon should not be placed too distally as this may result in a smaller (and solely right-sided) septal infarct, with a consequent reduction in the effect on the outflow gradient. Subsequently, an echocardiographic contrast agent (∼1ml SonoVue, Bracco, Geneva, Switzerland) was injected through the balloon, and the myocardium supplied by the septal artery localized with transthoracic echocardiography (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). The optimal location within the septum is the point of contact between the anterior mitral valve leaflet and septum in apical four-chamber view. If echocardiographic localization was supportive (no contrast seen outside the thickened basal septum), ablation could proceed. The transvenous pacing wire was re-checked, and intravenous analgesia administered, as the alcohol can cause intense but transient discomfort.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Absolute alcohol (1–3ml) was then administered slowly through the lumen of the balloon, for 3–5 minutes, followed by saline flush under continuous hemodynamic and ECG surveillance. The invasive and echocardiographic gradients were reassessed, a successful procedure being defined as a residual invasive LVOT pressure gradient of less than 50% of baseline value. If the target reduction in pressure gradient was not achieved, alcohol injection was repeated after 5 minutes (1–2ml) within the same perforator branch. If not successful, the procedure was repeated in a second perforator branch. Once success was achieved, the balloon was deflated, and coronary angiography was repeated to confirm the occlusion of the septal branch and the patency of the left anterior descending coronary artery (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D). Following deflation, the balloon and wire were removed.Patients were monitored in an intensive care unit for at least 48 hours after septal ablation, and the temporary pacemaker lead was kept in place for at least 24 hours.Data collection and follow-upDemographic characteristics, clinical history, echocardiographic and angiographic characteristics, procedural results and in-hospital outcomes were prospectively collected.Clinical follow-up was obtained in 100% of patients, by in-hospital or telephone interviews with the patient or family and/or review of medical records. Vital status, symptom recurrence, NYHA functional class, need for additional septal reduction therapy (such as surgical myectomy or repeat septal ablation), and possible complications related to septal ablation (such as ventricular arrhythmias or pacemaker dependency) were ascertained by follow-up evaluation. For deceased patients, cause of death was documented from hospital records.All patients underwent transthoracic echocardiography prior to, during and after the procedure (within the first 24 hours). Left ventricular diameters in end-diastole and end-systole were measured, as well as the thickness of the interventricular septum and left ventricular posterior wall. Left ventricular ejection fraction was accessed by the biplane Simpson method. The peak velocity in the LVOT at rest and after the Valsalva maneuver was measured by continuous wave Doppler echocardiography, and the gradient in the LVOT calculated using the modified Bernoulli equation. Mitral regurgitation was assessed semiquantitatively by color Doppler in four planes. Outpatient echocardiographic follow-up was obtained in 91.7% of patients, by protocol at 3, 6, 12 months and then on a yearly basis. A mean follow-up of 25±38 months was achieved.Statistical analysisStatistical analysis was performed using dedicated software (SPSS® version 18.0, 2009). Continuous variables were presented as mean values±standard deviation; categorical variables were expressed as frequencies. Comparisons were made using a Student's t-test for paired samples. The Kaplan–Meier method was used to estimate survival curves for the pre-determined end points with 95% confidence intervals. A p value of <0.05 was considered statistically significant.ResultsBaseline characteristicsPercutaneous ASA procedures were performed in 14 of 17 pre-selected patients with HOCM. In two patients the procedure was aborted due to echocardiographic evidence of echo-contrast staining of a large myocardial area, involving the basal and mid ventricular septum, with the consequent risk of serious complications; in a third patient, the procedure was interrupted before septal ablation due to a serious complication (see Procedural outcome). The baseline demographic, clinical and echocardiographic characteristics of the 14 patients who performed ASA (age 66.4±12.1 years; range 48–83 years; 71.4% women) are depicted in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. All patients had severe cardiovascular symptoms (NYHA class III/IV dyspnea, 78.6%; CCS class III/IV angina, 42.9%). Significant LVOT obstruction on echocardiography was present at rest in the majority of patients (n=11, mean peak LVOT gradient 104±40mmHg), being provocable in the others (n=3, mean peak LVOT gradient 75±22mmHg on Valsalva strain).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Procedural outcomePercutaneous ASA procedures were performed in 14 patients through the injection of 3.1±1.1ml of ethanol in a mean of 1.1±0.5 perforator septal branches. Invasive LV outflow tract peak pressure gradient decreased from 87±34mmHg at baseline (provoked peak gradient of 153±32mmHg) to 30±23mmHg immediately post-ASA (p=0.001). The acute success rate of ASA was 71.4%. Procedural complications occurred in 6.7% of patients – one case of left anterior descending coronary artery dissection while attempting to engage the septal branch with the guidewire, the procedure being interrupted (ASA not performed). Pacemaker implantation due to iatrogenic third-degree atrioventricular block was performed in four patients (28.6%). A significant rise in troponin T level was observed in all patients (mean peak level 62±60ng/ml).Echocardiographic evolutionThe long-term success rate among patients undergoing ASA was 85.7%. Echocardiographic resting peak LVOT gradient decreased from 104±40mmHg at baseline to 58±30mmHg post-procedure (p=0.03) and to 35±26mmHg at follow-up (p=0.001); total gradient decrease was 75±43mmHg (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). Ventricular septal thickness also decreased significantly during follow-up, from 24±5mm to 18±4mm (p=0.02). Mitral regurgitation showed a significant improvement, from grade 2.4±0.6 to 1.4±0.5 (p<0.001); only four patients remained with grade 2 mitral regurgitation. No significant alterations were found in any of the other echocardiographic parameters analyzed (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Clinical outcomeTwo deaths were recorded in the study population, both in-hospital (14.3%). One patient had a high-risk profile at the time of ASA (male, 83 years old, comorbidities, presentation with NYHA class III dyspnea and syncope, evolution in cardiogenic shock refractory to medical therapy, and rejected for surgical myectomy due to excessive risk); in addition, the procedure was unsuccessful (residual LVOT gradient 104mmHg). The patient evolved without clinical improvement, and died on day 9 post-procedure after an episode of ventricular fibrillation. The second patient was a 66-year-old woman with HOCM, admitted to the Emergency Department due to an episode of cardiorespiratory arrest in ventricular fibrillation, successfully resuscitated, in the context of NYHA class III dyspnea. Although percutaneous ASA was successful (acute fall of peak LVOT gradient from 83 to 37mmHg) and there were no procedural complications, the patient's clinical status did not improve, with evolution to cardiogenic shock and death in ventricular fibrillation 24 hours after the procedure.The remaining 12 patients had a largely uneventful short and long-term follow-up; only one patient suffered a transient ischemic attack in-hospital, without neurologic sequelae. No other deaths or ventricular arrhythmias were recorded during the mean 25-month clinical follow-up (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>Marked symptom improvement was also seen: dyspnea evolved from a mean NYHA functional class of 2.6±1.1 to 1.8±1.4 during follow-up (p=0.09); functional class improved in 81.8% of patients, from 78.3% of patients in class III–IV at baseline to 83.3% in class I–II at the end of follow-up (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>). No recurrence of angina or syncope was observed.<elsevierMultimedia ident="fig0025"></elsevierMultimedia>DiscussionOur results indicate that percutaneous alcohol septal ablation is an effective technique in the treatment of HOCM, in most patients (71.4%) yielding a significant acute fall in LVOT pressure gradient. This effect continues to progress throughout follow-up in most patients (85.7%), due to the gradual reduction in ventricular septal wall thickness secondary to alcohol-induced septal necrosis and consequent ventricular remodeling, with consequent clinical improvement in patients’ functional class.Echocardiographic analysisOur short- and long-term echocardiographic outcomes of the efficacy of ASA – significant reductions in LVOT pressure gradient, ventricular septal thickness and mitral regurgitation, without a significant drop in LV ejection fraction – were very positive.This evolution is in general agreement with the published data. A systematic review by Alam et al. in 2006 analyzed the results of ASA in 42 studies involving 2959 patients.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Echocardiographic analysis showed a sustained decrease at 12 months in resting LVOT gradient (65.3 to 15.8mmHg, p=0.001) with an associated reduction in basal septal diameter (20.9 to 13.9mm, p=0.001); LV ejection fraction decreased from 74.5% to 67.4% (p=0.001), with slight increases in LV end-diastolic (from 44.5mm to 45.8mm, p=0.001) and end-systolic (from 23.3mm to 26mm, p=0.001) diameters. It is generally agreed by most authors that 70–90% of treated patients show a significant acute LVOT gradient reduction; most of this acute fall likely represents stunning and consequent hypo- or akinesia of the basal septum, and may be followed by a recurrence of the gradient 1–3 days after ASA. Then, a permanent and more substantial reduction in the gradient develops progressively within 3–12 months of the procedure, the direct result of scar formation and thinning of the basal septum and of a LV remodeling process that appears to extend to the entire myocardium, leading to regression of LV hypertrophy. Indeed, total LV mass decreases after septal ablation and this reduction exceeds that of septal mass, findings that can be regarded as a result of the elimination (or at least reduction) of the pressure overload.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> A significant and sustained improvement in echocardiographic diastolic parameters post-ASA has also been shown.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Furthermore, and as seen in our study, ASA has been associated with a significant decrease and even abolition of systolic anterior motion and mitral regurgitation in long-term follow-up, and with a decrease in systolic pulmonary artery pressure.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> It is therefore prudent to allow for that time course before the treatment is deemed ineffective and any decision about repeat intervention is made.Clinical outcome and complicationsThe most impressive clinical result of our study was the clear symptomatic improvement of patients undergoing ASA: NYHA functional class improved in 81.8% after the procedure, only two patients remaining in NYHA class III (14.3%), and no cases of angina or syncope recurrence were observed during the mean 25-month clinical follow-up. Cardiac structural and functional changes are associated with a significant symptomatic improvement in HOCM patients undergoing percutaneous ASA. NYHA class is significantly lower after three months, with ongoing improvement during the first year.<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a> The above-mentioned systematic review showed a significant decrease in NYHA functional class (2.9 to 1.2, p=0.001) and angina (mean CCS class from 1.9 to 0.4, p=0.001), as well as an increase of 34% in mean treadmill exercise capacity (p=0.001) and of 33% in peak oxygen consumption (p=0.001) at 1-year follow-up.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>However, ASA is an interventional procedure and involves a non-negligible risk of complications. Serious complications were relatively uncommon in the same systematic review: early (30-day) mortality was 1.5% with a late mortality of 0.5%; ventricular fibrillation in the immediate preoperative period occurred in 2.2%, LAD dissection in 1.8%, and pericardial effusion in 0.6%. The most frequent complications were conduction disturbances: new right bundle branch block developed in 46% of patients and first degree atrioventricular block in 53% following ASA; permanent complete heart block requiring permanent pacemaker occurred in 10.5% of the patients treated. Rarer problems were coronary artery spasm, cardiogenic shock, pulmonary embolism and stroke.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Our in-hospital rate of complications was, in general, higher than that described: one procedural LAD dissection (6.7%) and three major in-hospital clinical events (two deaths and one transient ischemic attack, 21.4%). By contrast, no serious events (including death) occurred after the first 30 days. Our rate of permanent pacemaker implantation due to persistent third-degree atrioventricular block was also high (28.6%). While these numbers are cause for concern, three main factors may have influenced them: patient selection, the learning curve of the technique, and the small population size. Both deceased patients were very high-risk cases: the first presented in refractory cardiogenic shock, ASA having been performed with strictly life-saving objectives, while the second had been admitted due to cardiorespiratory arrest in ventricular fibrillation. While they may reflect real-world practice, these patients are not representative of those included in clinical trials. The learning curve is also an unavoidable issue when a first series of cases of any technique is presented; percutaneous ASA is a complex procedure, in which most of the complications occur in the catheterization laboratory or during the early post-interventional period, and a moderate to extended learning curve effect is to be expected. While earlier series have shown in-hospital mortality rates of around 4%, these have now fallen to around 1.5%. It seems clear that improved expertise might be an integral part of refinement of the procedure, with subsequent falls in the complication rate.<a class="elsevierStyleCrossRefs" href="#bib0045">9,14</a> Technical advances, reflected in our series (which represents 10 years of evolution), have also influenced ASA prognosis: for instance, the introduction of echocardiographic contrast guidance has essentially eliminated the risk of inducing apical or lateral wall infarcts due to the presence of septal collaterals to these areas, and the use of lower doses (≤2ml) of ethanol has been associated with lower incidence of permanent pacemaker implantation and greater survival benefit.<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a> Finally, it should not be overlooked that the small size of the sample analyzed makes it difficult to discount the effect of chance on the results.Percutaneous alcohol septal ablation versus surgical myectomyWhile this was not the aim of our study, it important to contextualize our results with those obtained by alternative techniques. Since its introduction by Sigwart in 1994, ASA has been performed in thousands of patients with HOCM with good short-term results.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> However, there have been no randomized control trials comparing the efficacy and outcomes of percutaneous ASA and surgical myectomy. Several non-randomized comparative studies were recently analyzed in both a meta-analysis (Alam et al., 2009, involving five studies and 351 patients) and a systematic review (Leonardi et al., 2010, involving 27 studies and 4094 patients).<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> The results show that both therapeutic modalities offer similar significant reductions in LVOT obstruction and symptomatic improvement, as well as similarly low all-cause in-hospital and long-term mortality and sudden cardiac death. Myectomy is associated with a lower risk of complete AV block necessitating permanent pacemaker implantation, although at the cost of a higher risk of stroke and a longer postoperative recovery period; following ASA, a higher number of patients required a second procedure (either repeat ASA or myectomy) because of an unsatisfactory result.<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a> Therefore, in view of these emerging long-term results, surgery and percutaneous septal ablation should be regarded as alternative treatment options in HOCM, in terms of safety and efficacy. It is prudent to take account of the benefits and drawbacks of each therapeutic method when deciding on treatment for LVOT obstruction, taking into consideration clinical, morphological, and technical aspects, the individual experience of the center and the merit of each treatment modality for the individual patient.Study limitationsThe present study has a retrospective design, and intervened patients were subject to selection bias, which must be considered in the interpretation of its results. Most importantly, the small population analyzed limited the statistical analysis of the results and their extrapolability. Despite these limitations, our study benefits from technical consistency between patients and a careful long-term clinical and echocardiographic follow-up, factors reflected in significant results that are very similar to the published data. Most of all, it was never our intention to analyze a representative population or to reach innovative conclusions, but only to perform and share a critical self-evaluation of our initial practice in this area.ConclusionsPercutaneous ASA was shown to be an effective alternative therapy in patients with severe symptomatic HOCM refractory to medical treatment. In this population it was associated with significant acute and long-term falls in LVOT pressure gradient, ventricular septal thickness and mitral regurgitation, accompanied by clear functional improvement in long-term follow-up. However, this invasive technique was not free of procedural and periprocedural complications, underlining the importance of careful patient selection and of the technical expertise of the center. Alcohol septal ablation is still evolving, and it is hoped that refinements in the technique will lead to further improvement in outcomes.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres176200" "titulo" => array:5 [ 0 => "Abstract" 1 => "Background" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec164574" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres176201" "titulo" => array:5 [ 0 => "Resumo" 1 => "Objetivos" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusões" ] ] 3 => array:2 [ "identificador" => "xpalclavsec164575" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Percutaneous alcohol septal ablation procedure" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Data collection and follow-up" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Baseline characteristics" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Procedural outcome" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Echocardiographic evolution" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Clinical outcome" ] ] ] 7 => array:3 [ "identificador" => "sec0060" "titulo" => "Discussion" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Echocardiographic analysis" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Clinical outcome and complications" ] 2 => array:2 [ "identificador" => "sec0075" "titulo" => "Percutaneous alcohol septal ablation versus surgical myectomy" ] 3 => array:2 [ "identificador" => "sec0080" "titulo" => "Study limitations" ] ] ] 8 => array:2 [ "identificador" => "sec0085" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0090" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack45110" "titulo" => "Acknowledgment" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-06-07" "fechaAceptado" => "2011-11-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec164574" "palabras" => array:4 [ 0 => "Hypertrophic obstructive cardiomyopathy" 1 => "Alcohol septal ablation" 2 => "Myectomy" 3 => "Prognosis" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec164575" "palabras" => array:4 [ 0 => "Cardiomiopatia hipertrófica obstrutiva" 1 => "Ablação septal alcoólica" 2 => "Miectomia" 3 => "Prognóstico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "BackgroundPercutaneous septal ablation by alcohol-induced septal branch occlusion was introduced as a new treatment option in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). Our aim was to evaluate procedural and long-term clinical and echocardiographic outcomes in patients with HOCM treated by alcohol septal ablation (ASA) at our center. MethodsThis single-center retrospective study included 14 consecutive HOCM patients undergoing percutaneous ASA (66.4±12.1 years, 71.4% female). At baseline all patients presented persistent symptoms despite optimized medical treatment, left ventricular outflow tract (LVOT) obstruction with a peak gradient >50mmHg, systolic anterior motion of the mitral valve, and ventricular septal thickness ≥15mm. ASA was considered successful when the LVOT pressure gradient fell to less than 50% of baseline value. All patients had echocardiographic evaluation at baseline, intraprocedure and at follow-up, and a long-term clinical follow-up (25±38 months) with evaluation of functional class and occurrence of symptoms or cardiovascular events. ResultsPercutaneous ASA achieved a 71.4% acute and 85.7% long-term success rate. Peak LVOT gradient decreased from 104±40mmHg at baseline to 58±30mmHg intraprocedure (p=0.03) and 35±26mmHg at follow-up (p=0.001); total gradient decrease was 75±43mmHg. Ventricular septal thickness and mitral regurgitation also presented significant decreases during follow-up (from 24±5mm to 18±4mm, p=0.02, and from grade 2.4±0.6 to 1.4±0.5, p<0.001, respectively). A tendency for long-term improvement in NYHA functional class (from 2.6±1.1 to 1.8±1.4, p=0.09) was observed. Procedural complications occurred in 6.7% of patients; two deaths and one transient ischemic attack occurred in-hospital, but no long-term clinical events were recorded. ConclusionsPercutaneous ASA is an effective treatment for symptomatic patients with HOCM, obtaining a marked decrease in LVOT pressure gradient and symptomatic improvement. Despite the occurrence of a significant number of procedural complications, the favorable long-term outcomes underline the potential of ASA as a percutaneous alternative to surgical myectomy." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "ObjetivosA ablação septal percutânea por indução alcoólica da oclusão de ramos coronários septais foi introduzida como uma nova opção terapêutica em doentes com cardiomiopatia hipertrófica obstrutiva (HOCM) sintomática. O nosso objetivo foi a avaliação dos resultados clínicos e ecocardiográficos agudos e a longo-prazo em doentes com HOCM tratados por ablação septal alcoólica (ASA) no nosso centro. MétodosEstudo monocêntrico, retrospetivo incluindo 14 doentes consecutivos com HOCM submetidos a ASA percutânea (66,4±12,1 anos, 71,4% sexo feminino). Todos os doentes apresentavam basalmente sintomas persistentes apesar de terapêutica médica otimizada, obstrução da câmara de saída do ventrículo esquerdo (LVOT) com gradiente máximo >50mmHg, movimento sistólico anterior da válvula mitral e espessura do septo interventricular ≥15mm. A ASA foi considerada bem sucedida quando o gradiente do LVOT diminuiu para menos de 50% do valor inicial. Todos os doentes foram submetidos a avaliação clínica e ecocardiográfica basal, intraprocedimento e durante o seguimento, com avaliação da classe funcional e ocorrência de sintomas ou eventos cardiovasculares a longo-prazo (25±38 meses). ResultadosA ASA percutânea obteve uma taxa de sucesso de 71,4% e 85,7%, respetivamente aguda e a longo-prazo. O gradiente máximo do LVOT diminuiu de 104±40mmHg basais para 58±30mmHg intraprocedimento (p=0,03) e 35±26mmHg a longo-prazo (p=0,001); o decréscimo total do gradiente foi de 75±43mmHg. Também a espessura do septo interventricular e a regurgitação mitral apresentaram uma diminuição significativa durante o seguimento (de 24±5mm para 18±4mm, p=0,02, e de grau 2,4±0,6 para 1,4±0,5, p<0,001, respetivamente). Uma tendência para a melhoria a longo-prazo da classe funcional NYHA (de 2,6±1,1 to 1,8±1,4, p=0,09) foi observada. Complicações do procedimento ocorreram em 6,7% dos doentes; duas mortes e um acidente isquémico transitório ocorreram no hospital, não se registando eventos clínicos a longo-prazo. ConclusõesA ASA percutânea é uma terapêutica eficaz para doentes sintomáticos com HOCM, obtendo uma acentuada diminuição do gradiente de pressão do LVOT e melhoria sintomática. Apesar da ocorrência de um número significativo de complicações periprocedimento, o favorável prognóstico a longo-prazo sublinha o potencial da ASA como uma alternativa percutânea à miectomia cirúrgica." ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2728 "Ancho" => 2917 "Tamanyo" => 626038 ] ] "descripcion" => array:1 [ "en" => "Angiographic demonstration of alcohol septal ablation technique. Left coronary angiography shows the target septal branch (arrow); an angioplasty guidewire is already inserted inside the septal branch (A). Optimal positioning of the balloon catheter (arrow) in the proximal part of the septal artery without compromise of the left anterior descending artery (B). Injection of angiographic contrast dye through the central lumen of the inflated balloon catheter (arrow) determines the supply area of the septal branch and excludes leakage into the left anterior descending artery or other coronary vessels (C). Final demonstration of the septal artery stump (arrow) after alcohol-induced occlusion (D)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1333 "Ancho" => 3000 "Tamanyo" => 210077 ] ] "descripcion" => array:1 [ "en" => "Myocardial contrast echocardiography during alcohol septal ablation. First, the anatomy of the heart is presented and the target septal area is identified (A). Injection of echocardiographic contrast into the target septal branch opacifies the basal part of the septum, verifying the optimal choice of septal branch (B). A more sustained opacification of the basal septum after alcohol injection signifies a good alcohol depot (C)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1111 "Ancho" => 2092 "Tamanyo" => 97909 ] ] "descripcion" => array:1 [ "en" => "Echocardiographic evolution of resting left ventricular outflow tract peak gradient in patients undergoing percutaneous alcohol septal ablation. LVOT: left ventricular outflow tract." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 959 "Ancho" => 2025 "Tamanyo" => 78413 ] ] "descripcion" => array:1 [ "en" => "Overall survival after percutaneous alcohol septal ablation." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 662 "Ancho" => 1235 "Tamanyo" => 41467 ] ] "descripcion" => array:1 [ "en" => "Evolution of New York Heart Association (NYHA) class from baseline to end of follow-up in patients undergoing alcohol septal ablation." ] ] 5 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "Values are presented as number (%) or as mean±standard deviation, unless otherwise stated. CCS: Canadian Cardiovascular Society; HCM: hypertrophic cardiomyopathy; ICD: implantable cardioverter-defibrillator; LV: left ventricular; LVOT: left ventricular outflow tract; NYHA: New York Heart Association; PPM: permanent pacemaker; SCD: sudden cardiac death." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Baseline characteristics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">n=14 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Demographics</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66.4±12.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (71.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical presentation</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NYHA class III or IV dyspnea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (78.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CCS class III or IV angina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (42.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Syncope \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (21.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ventricular arrhythmias \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Comorbidities and medical history</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Arterial hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (50.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coronary artery disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (6.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cerebrovascular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atrial fibrillation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (28.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Previous PPM/ICD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Family history of HCM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Family history of SCD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medical therapy</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Beta-blockers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (78.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Calcium channel antagonists \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (50.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Disopyramide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Echocardiographic data</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ventricular septal thickness, mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24±5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV posterior wall thickness, mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17±4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV end-diastolic diameter, mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43±9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV ejection fraction (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73±9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Resting LVOT pressure gradient, mmHg <a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">104±40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Provocable LVOT pressure gradient, mmHg <a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75±22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mitral regurgitation, grade \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.4±0.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Organic mitral valve disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab268782.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Parameter measured in 11 patients." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Parameter measured in three patients." ] ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics of the population undergoing percutaneous alcohol septal ablation." ] ] 6 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Values are presented as mean±standard deviation. LV: left ventricular; LVOT: left ventricular outflow tract." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Echocardiographic parameters \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Follow-up \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Resting LVOT pressure gradient, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">104±40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35±26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ventricular septal thickness, mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24±5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18±4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.02 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mitral regurgitation, grade \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.4±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.4±0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV posterior wall thickness, mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17±4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15±3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV end-diastolic diameter, mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43±9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43±8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.81 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV ejection fraction, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73±9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68±12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.48 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab268783.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Evolution of echocardiographic parameters during follow-up." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The 50-year history, controversy, and clinical implications of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy: from idiopathic hypertrophic subaortic stenosis to hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B. Maron" 1 => "M. Maron" 2 => "D. Wigle" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2008.11.069" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2009" "volumen" => "54" "paginaInicial" => "191" "paginaFinal" => "200" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19589431" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long-term effects of surgical septal myectomy on survival in patients with obstructive hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S.R. Ommen" 1 => "B.J. Maron" 2 => "I. Olivotto" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2005.02.090" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2005" "volumen" => "46" "paginaInicial" => "470" "paginaFinal" => "476" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16053960" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The management of hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. Spirito" 1 => "C.E. Seidman" 2 => "W.J. 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Original Article

Percutaneous alcohol septal ablation for hypertrophic obstructive cardiomyopathy: Technical review and long-term clinical and echocardiographic outcomes

Ablação septal alcoólica percutânea na cardiomiopatia hipertrófica obstrutiva: revisão da técnica e resultados clínicos e ecocardiográficos a longo-prazo

Sílvio Leala,b,

Corresponding author

silvionleal@gmail.com

Corresponding author.

, Guillermo Galeoteb, Santiago Jiménez-Valerob, Ángel Sánchez-Recaldeb, Pablo Salinasb, Alejandro Sáez Ruizb, Luís Calvo Orbeb, Francisco Dominguézb, Raúl Morenob, José Luís López-Sendónb

a Unidade de Intervenção Cardiovascular, Serviço de Cardiologia, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal

b Unidad de Cardiologia Intervencionista, Servicio de Cardiologia, Hospital Universitario La Paz, Madrid, Spain

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        "titulo" => "Abla&#231;&#227;o septal alco&#243;lica percut&#226;nea na cardiomiopatia hipertr&#243;fica obstrutiva&#58; revis&#227;o da t&#233;cnica e resultados cl&#237;nicos e ecocardiogr&#225;ficos a longo-prazo"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Myocardial contrast echocardiography during alcohol septal ablation&#46; First&#44; the anatomy of the heart is presented and the target septal area is identified &#40;A&#41;&#46; Injection of echocardiographic contrast into the target septal branch opacifies the basal part of the septum&#44; verifying the optimal choice of septal branch &#40;B&#41;&#46; A more sustained opacification of the basal septum after alcohol injection signifies a good alcohol depot &#40;C&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hypertrophic obstructive cardiomyopathy &#40;HOCM&#41;&#44; first described in the late 1950s&#44; is now recognized to be a primary autosomal dominant myocardial disorder characterized by a dynamic narrowing of the left ventricular outflow tract &#40;LVOT&#41;&#44; secondary to asymmetrical septal hypertrophy and systolic anterior motion of the mitral valve&#46; The consequent reduction in cardiac output is responsible for the typical symptoms of dyspnea&#44; angina pectoris and stress-induced syncope&#44; with increased risk for sudden cardiac death in some patients&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Treatment of patients with symptomatic HOCM aims to reduce functional disability and the extent of outflow tract obstruction and to improve diastolic filling and survival in a disease with a mortality rate estimated at 3&#8211;4&#37; per year&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Administration of negatively inotropic drugs is the treatment of first choice&#44; and succeeds in improving functional capacity and symptoms in a high percentage of patients&#46; However&#44; 5&#8211;10&#37; of patients with marked LVOT obstruction have severe symptoms unresponsive to medical therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Such patients have traditionally been referred for surgical myectomy of the basal septum&#44; which has been the gold standard treatment for decades&#46; This procedure relieves left ventricular &#40;LV&#41; outflow obstruction&#44; providing long-term symptomatic and outcome improvement in most patients&#44; with a mortality of 1&#8211;2&#37; in experienced centers&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Percutaneous alcohol septal ablation &#40;ASA&#41; has emerged as a novel interventional treatment option during the last decade&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This technique&#44; in which ethanol is injected into one or more septal perforator branches of the left anterior descending coronary artery&#44; achieves a circumscribed infarction of the area supplied by the occluded septal branch&#44; reducing the hypertrophied interventricular septum with consequent expansion of LVOT area and gradient reduction&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The acute and long-term efficacy of ASA has been proven&#44; with hemodynamic results resembling those of myectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of the present study was to evaluate the acute and long-term clinical and echocardiographic outcome of patients with symptomatic HOCM treated by percutaneous ASA in our center&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Study population</span><p id="par0025" class="elsevierStylePara elsevierViewall">The study included 14 consecutive patients with HOCM who underwent ASA between 1999 and 2010 at the Interventional Cardiology Unit of Hospital La Paz&#44; Madrid&#44; Spain&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The diagnosis of HOCM was based on typical clinical&#44; electrocardiographic&#44; and echocardiographic features&#44; with ventricular myocardial hypertrophy occurring in the absence of any other cardiac or systemic cause&#46; The magnitude of myocardial hypertrophy was assessed by M-mode and two-dimensional transthoracic echocardiography&#44; using standard techniques&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Eligibility criteria for ASA were&#58; &#40;1&#41; persistent severe symptoms&#44; defined as New York Heart Association &#40;NYHA&#41; class III or IV dyspnea and&#47;or Canadian Cardiovascular Society &#40;CCS&#41; class III or IV angina&#44; despite optimized medical treatment&#59; &#40;2&#41; dynamic LVOT obstruction &#40;peak gradient &#62;50<span class="elsevierStyleHsp" style=""></span>mmHg at rest or provocable&#41; caused by systolic anterior motion of the mitral valve&#59; &#40;3&#41; ventricular septal thickness &#8805;15 mm&#59; &#40;4&#41; absence of significant intrinsic mitral valve disease&#59; and &#40;5&#41; absence of need for concomitant cardiac surgical procedure &#40;such as bypass grafting or valve replacement&#41;&#46; All patients gave written informed consent for the procedure&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Percutaneous alcohol septal ablation procedure</span><p id="par0040" class="elsevierStylePara elsevierViewall">ASA procedures started by obtaining arterial and venous femoral accesses&#44; using the standard Judkins technique&#44; followed by placement of a 6F temporary transvenous pacemaker lead in the right ventricular apex&#44; a 5F pigtail or multipurpose catheter into the LV&#44; and a 6F or 7F guiding catheter in the ascending aorta&#46; Re-evaluation of the patient&#39;s hemodynamics and re-measurement of the intracavitary gradient were then performed and continuously monitored throughout the procedure&#44; through simultaneous pressure measurement in the LV and the aorta&#46; Physiologic provocation of the gradient was assessed with the Valsalva maneuver and checking for the Brockenbrough-Braunwald-Morrow sign by inducing a premature ventricular complex&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Coronary angiography was then performed to exclude severe coronary disease and to locate the first septal perforator artery&#46; A 0&#46;014-in&#46; guidewire was advanced to engage&#44; in most cases&#44; the first septal branch of the left anterior descending artery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#41;&#46; A slightly oversized&#44; short &#40;&#8764;10<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; over-the-wire angioplasty balloon was then introduced into the septal perforator artery&#44; using standard methods&#59; the lumen of this device provides the route for selective delivery of angiographic contrast&#44; echo contrast&#44; and ultimately alcohol&#44; into the septal artery&#46; After careful fluoroscopic positioning of the balloon &#40;using selective angiography to exclude encroachment onto the LAD&#41;&#44; it was inflated and the guidewire removed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">A small amount of angiographic contrast was then injected through the balloon lumen to ensure that there was no spill-back into the LAD or collateral recruitment &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C&#41;&#46; The balloon should not be placed too distally as this may result in a smaller &#40;and solely right-sided&#41; septal infarct&#44; with a consequent reduction in the effect on the outflow gradient&#46; Subsequently&#44; an echocardiographic contrast agent &#40;&#8764;1<span class="elsevierStyleHsp" style=""></span>ml SonoVue&#44; Bracco&#44; Geneva&#44; Switzerland&#41; was injected through the balloon&#44; and the myocardium supplied by the septal artery localized with transthoracic echocardiography &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; The optimal location within the septum is the point of contact between the anterior mitral valve leaflet and septum in apical four-chamber view&#46; If echocardiographic localization was supportive &#40;no contrast seen outside the thickened basal septum&#41;&#44; ablation could proceed&#46; The transvenous pacing wire was re-checked&#44; and intravenous analgesia administered&#44; as the alcohol can cause intense but transient discomfort&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Absolute alcohol &#40;1&#8211;3<span class="elsevierStyleHsp" style=""></span>ml&#41; was then administered slowly through the lumen of the balloon&#44; for 3&#8211;5 minutes&#44; followed by saline flush under continuous hemodynamic and ECG surveillance&#46; The invasive and echocardiographic gradients were reassessed&#44; a successful procedure being defined as a residual invasive LVOT pressure gradient of less than 50&#37; of baseline value&#46; If the target reduction in pressure gradient was not achieved&#44; alcohol injection was repeated after 5 minutes &#40;1&#8211;2<span class="elsevierStyleHsp" style=""></span>ml&#41; within the same perforator branch&#46; If not successful&#44; the procedure was repeated in a second perforator branch&#46; Once success was achieved&#44; the balloon was deflated&#44; and coronary angiography was repeated to confirm the occlusion of the septal branch and the patency of the left anterior descending coronary artery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D&#41;&#46; Following deflation&#44; the balloon and wire were removed&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Patients were monitored in an intensive care unit for at least 48 hours after septal ablation&#44; and the temporary pacemaker lead was kept in place for at least 24 hours&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Data collection and follow-up</span><p id="par0065" class="elsevierStylePara elsevierViewall">Demographic characteristics&#44; clinical history&#44; echocardiographic and angiographic characteristics&#44; procedural results and in-hospital outcomes were prospectively collected&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Clinical follow-up was obtained in 100&#37; of patients&#44; by in-hospital or telephone interviews with the patient or family and&#47;or review of medical records&#46; Vital status&#44; symptom recurrence&#44; NYHA functional class&#44; need for additional septal reduction therapy &#40;such as surgical myectomy or repeat septal ablation&#41;&#44; and possible complications related to septal ablation &#40;such as ventricular arrhythmias or pacemaker dependency&#41; were ascertained by follow-up evaluation&#46; For deceased patients&#44; cause of death was documented from hospital records&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">All patients underwent transthoracic echocardiography prior to&#44; during and after the procedure &#40;within the first 24 hours&#41;&#46; Left ventricular diameters in end-diastole and end-systole were measured&#44; as well as the thickness of the interventricular septum and left ventricular posterior wall&#46; Left ventricular ejection fraction was accessed by the biplane Simpson method&#46; The peak velocity in the LVOT at rest and after the Valsalva maneuver was measured by continuous wave Doppler echocardiography&#44; and the gradient in the LVOT calculated using the modified Bernoulli equation&#46; Mitral regurgitation was assessed semiquantitatively by color Doppler in four planes&#46; Outpatient echocardiographic follow-up was obtained in 91&#46;7&#37; of patients&#44; by protocol at 3&#44; 6&#44; 12 months and then on a yearly basis&#46; A mean follow-up of 25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>38 months was achieved&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using dedicated software &#40;SPSS<span class="elsevierStyleSup">&#174;</span> version 18&#46;0&#44; 2009&#41;&#46; Continuous variables were presented as mean values<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#59; categorical variables were expressed as frequencies&#46; Comparisons were made using a Student&#39;s t-test for paired samples&#46; The Kaplan&#8211;Meier method was used to estimate survival curves for the pre-determined end points with 95&#37; confidence intervals&#46; A <span class="elsevierStyleItalic">p</span> value of &#60;0&#46;05 was considered statistically significant&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Baseline characteristics</span><p id="par0085" class="elsevierStylePara elsevierViewall">Percutaneous ASA procedures were performed in 14 of 17 pre-selected patients with HOCM&#46; In two patients the procedure was aborted due to echocardiographic evidence of echo-contrast staining of a large myocardial area&#44; involving the basal and mid ventricular septum&#44; with the consequent risk of serious complications&#59; in a third patient&#44; the procedure was interrupted before septal ablation due to a serious complication &#40;see <span class="elsevierStyleItalic">Procedural outcome</span>&#41;&#46; The baseline demographic&#44; clinical and echocardiographic characteristics of the 14 patients who performed ASA &#40;age 66&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;1 years&#59; range 48&#8211;83 years&#59; 71&#46;4&#37; women&#41; are depicted in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; All patients had severe cardiovascular symptoms &#40;NYHA class III&#47;IV dyspnea&#44; 78&#46;6&#37;&#59; CCS class III&#47;IV angina&#44; 42&#46;9&#37;&#41;&#46; Significant LVOT obstruction on echocardiography was present at rest in the majority of patients &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#44; mean peak LVOT gradient 104<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; being provocable in the others &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#44; mean peak LVOT gradient 75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22<span class="elsevierStyleHsp" style=""></span>mmHg on Valsalva strain&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Procedural outcome</span><p id="par0090" class="elsevierStylePara elsevierViewall">Percutaneous ASA procedures were performed in 14 patients through the injection of 3&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;1<span class="elsevierStyleHsp" style=""></span>ml of ethanol in a mean of 1&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5 perforator septal branches&#46; Invasive LV outflow tract peak pressure gradient decreased from 87<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>34<span class="elsevierStyleHsp" style=""></span>mmHg at baseline &#40;provoked peak gradient of 153<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32<span class="elsevierStyleHsp" style=""></span>mmHg&#41; to 30<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23<span class="elsevierStyleHsp" style=""></span>mmHg immediately post-ASA &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The acute success rate of ASA was 71&#46;4&#37;&#46; Procedural complications occurred in 6&#46;7&#37; of patients &#8211; one case of left anterior descending coronary artery dissection while attempting to engage the septal branch with the guidewire&#44; the procedure being interrupted &#40;ASA not performed&#41;&#46; Pacemaker implantation due to iatrogenic third-degree atrioventricular block was performed in four patients &#40;28&#46;6&#37;&#41;&#46; A significant rise in troponin T level was observed in all patients &#40;mean peak level 62<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Echocardiographic evolution</span><p id="par0095" class="elsevierStylePara elsevierViewall">The long-term success rate among patients undergoing ASA was 85&#46;7&#37;&#46; Echocardiographic resting peak LVOT gradient decreased from 104<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>mmHg at baseline to 58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mmHg post-procedure &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41; and to 35<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26<span class="elsevierStyleHsp" style=""></span>mmHg at follow-up &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#59; total gradient decrease was 75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>43<span class="elsevierStyleHsp" style=""></span>mmHg &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; Ventricular septal thickness also decreased significantly during follow-up&#44; from 24<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm to 18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>mm &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#46; Mitral regurgitation showed a significant improvement&#44; from grade 2&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;6 to 1&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#59; only four patients remained with grade 2 mitral regurgitation&#46; No significant alterations were found in any of the other echocardiographic parameters analyzed &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical outcome</span><p id="par0100" class="elsevierStylePara elsevierViewall">Two deaths were recorded in the study population&#44; both in-hospital &#40;14&#46;3&#37;&#41;&#46; One patient had a high-risk profile at the time of ASA &#40;male&#44; 83 years old&#44; comorbidities&#44; presentation with NYHA class III dyspnea and syncope&#44; evolution in cardiogenic shock refractory to medical therapy&#44; and rejected for surgical myectomy due to excessive risk&#41;&#59; in addition&#44; the procedure was unsuccessful &#40;residual LVOT gradient 104<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46; The patient evolved without clinical improvement&#44; and died on day 9 post-procedure after an episode of ventricular fibrillation&#46; The second patient was a 66-year-old woman with HOCM&#44; admitted to the Emergency Department due to an episode of cardiorespiratory arrest in ventricular fibrillation&#44; successfully resuscitated&#44; in the context of NYHA class III dyspnea&#46; Although percutaneous ASA was successful &#40;acute fall of peak LVOT gradient from 83 to 37<span class="elsevierStyleHsp" style=""></span>mmHg&#41; and there were no procedural complications&#44; the patient&#39;s clinical status did not improve&#44; with evolution to cardiogenic shock and death in ventricular fibrillation 24 hours after the procedure&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The remaining 12 patients had a largely uneventful short and long-term follow-up&#59; only one patient suffered a transient ischemic attack in-hospital&#44; without neurologic sequelae&#46; No other deaths or ventricular arrhythmias were recorded during the mean 25-month clinical follow-up &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Marked symptom improvement was also seen&#58; dyspnea evolved from a mean NYHA functional class of 2&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;1 to 1&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;4 during follow-up &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;09&#41;&#59; functional class improved in 81&#46;8&#37; of patients&#44; from 78&#46;3&#37; of patients in class III&#8211;IV at baseline to 83&#46;3&#37; in class I&#8211;II at the end of follow-up &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>&#41;&#46; No recurrence of angina or syncope was observed&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">Our results indicate that percutaneous alcohol septal ablation is an effective technique in the treatment of HOCM&#44; in most patients &#40;71&#46;4&#37;&#41; yielding a significant acute fall in LVOT pressure gradient&#46; This effect continues to progress throughout follow-up in most patients &#40;85&#46;7&#37;&#41;&#44; due to the gradual reduction in ventricular septal wall thickness secondary to alcohol-induced septal necrosis and consequent ventricular remodeling&#44; with consequent clinical improvement in patients&#8217; functional class&#46;</p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Echocardiographic analysis</span><p id="par0120" class="elsevierStylePara elsevierViewall">Our short- and long-term echocardiographic outcomes of the efficacy of ASA &#8211; significant reductions in LVOT pressure gradient&#44; ventricular septal thickness and mitral regurgitation&#44; without a significant drop in LV ejection fraction &#8211; were very positive&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">This evolution is in general agreement with the published data&#46; A systematic review by Alam et al&#46; in 2006 analyzed the results of ASA in 42 studies involving 2959 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Echocardiographic analysis showed a sustained decrease at 12 months in resting LVOT gradient &#40;65&#46;3 to 15&#46;8<span class="elsevierStyleHsp" style=""></span>mmHg&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; with an associated reduction in basal septal diameter &#40;20&#46;9 to 13&#46;9<span class="elsevierStyleHsp" style=""></span>mm&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#59; LV ejection fraction decreased from 74&#46;5&#37; to 67&#46;4&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; with slight increases in LV end-diastolic &#40;from 44&#46;5<span class="elsevierStyleHsp" style=""></span>mm to 45&#46;8<span class="elsevierStyleHsp" style=""></span>mm&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and end-systolic &#40;from 23&#46;3<span class="elsevierStyleHsp" style=""></span>mm to 26<span class="elsevierStyleHsp" style=""></span>mm&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; diameters&#46; It is generally agreed by most authors that 70&#8211;90&#37; of treated patients show a significant acute LVOT gradient reduction&#59; most of this acute fall likely represents stunning and consequent hypo- or akinesia of the basal septum&#44; and may be followed by a recurrence of the gradient 1&#8211;3 days after ASA&#46; Then&#44; a permanent and more substantial reduction in the gradient develops progressively within 3&#8211;12 months of the procedure&#44; the direct result of scar formation and thinning of the basal septum and of a LV remodeling process that appears to extend to the entire myocardium&#44; leading to regression of LV hypertrophy&#46; Indeed&#44; total LV mass decreases after septal ablation and this reduction exceeds that of septal mass&#44; findings that can be regarded as a result of the elimination &#40;or at least reduction&#41; of the pressure overload&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> A significant and sustained improvement in echocardiographic diastolic parameters post-ASA has also been shown&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Furthermore&#44; and as seen in our study&#44; ASA has been associated with a significant decrease and even abolition of systolic anterior motion and mitral regurgitation in long-term follow-up&#44; and with a decrease in systolic pulmonary artery pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> It is therefore prudent to allow for that time course before the treatment is deemed ineffective and any decision about repeat intervention is made&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical outcome and complications</span><p id="par0130" class="elsevierStylePara elsevierViewall">The most impressive clinical result of our study was the clear symptomatic improvement of patients undergoing ASA&#58; NYHA functional class improved in 81&#46;8&#37; after the procedure&#44; only two patients remaining in NYHA class III &#40;14&#46;3&#37;&#41;&#44; and no cases of angina or syncope recurrence were observed during the mean 25-month clinical follow-up&#46; Cardiac structural and functional changes are associated with a significant symptomatic improvement in HOCM patients undergoing percutaneous ASA&#46; NYHA class is significantly lower after three months&#44; with ongoing improvement during the first year&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> The above-mentioned systematic review showed a significant decrease in NYHA functional class &#40;2&#46;9 to 1&#46;2&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and angina &#40;mean CCS class from 1&#46;9 to 0&#46;4&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; as well as an increase of 34&#37; in mean treadmill exercise capacity &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and of 33&#37; in peak oxygen consumption &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; at 1-year follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">However&#44; ASA is an interventional procedure and involves a non-negligible risk of complications&#46; Serious complications were relatively uncommon in the same systematic review&#58; early &#40;30-day&#41; mortality was 1&#46;5&#37; with a late mortality of 0&#46;5&#37;&#59; ventricular fibrillation in the immediate preoperative period occurred in 2&#46;2&#37;&#44; LAD dissection in 1&#46;8&#37;&#44; and pericardial effusion in 0&#46;6&#37;&#46; The most frequent complications were conduction disturbances&#58; new right bundle branch block developed in 46&#37; of patients and first degree atrioventricular block in 53&#37; following ASA&#59; permanent complete heart block requiring permanent pacemaker occurred in 10&#46;5&#37; of the patients treated&#46; Rarer problems were coronary artery spasm&#44; cardiogenic shock&#44; pulmonary embolism and stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Our in-hospital rate of complications was&#44; in general&#44; higher than that described&#58; one procedural LAD dissection &#40;6&#46;7&#37;&#41; and three major in-hospital clinical events &#40;two deaths and one transient ischemic attack&#44; 21&#46;4&#37;&#41;&#46; By contrast&#44; no serious events &#40;including death&#41; occurred after the first 30 days&#46; Our rate of permanent pacemaker implantation due to persistent third-degree atrioventricular block was also high &#40;28&#46;6&#37;&#41;&#46; While these numbers are cause for concern&#44; three main factors may have influenced them&#58; patient selection&#44; the learning curve of the technique&#44; and the small population size&#46; Both deceased patients were very high-risk cases&#58; the first presented in refractory cardiogenic shock&#44; ASA having been performed with strictly life-saving objectives&#44; while the second had been admitted due to cardiorespiratory arrest in ventricular fibrillation&#46; While they may reflect real-world practice&#44; these patients are not representative of those included in clinical trials&#46; The learning curve is also an unavoidable issue when a first series of cases of any technique is presented&#59; percutaneous ASA is a complex procedure&#44; in which most of the complications occur in the catheterization laboratory or during the early post-interventional period&#44; and a moderate to extended learning curve effect is to be expected&#46; While earlier series have shown in-hospital mortality rates of around 4&#37;&#44; these have now fallen to around 1&#46;5&#37;&#46; It seems clear that improved expertise might be an integral part of refinement of the procedure&#44; with subsequent falls in the complication rate&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;14</span></a> Technical advances&#44; reflected in our series &#40;which represents 10 years of evolution&#41;&#44; have also influenced ASA prognosis&#58; for instance&#44; the introduction of echocardiographic contrast guidance has essentially eliminated the risk of inducing apical or lateral wall infarcts due to the presence of septal collaterals to these areas&#44; and the use of lower doses &#40;&#8804;2<span class="elsevierStyleHsp" style=""></span>ml&#41; of ethanol has been associated with lower incidence of permanent pacemaker implantation and greater survival benefit&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> Finally&#44; it should not be overlooked that the small size of the sample analyzed makes it difficult to discount the effect of chance on the results&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Percutaneous alcohol septal ablation versus surgical myectomy</span><p id="par0145" class="elsevierStylePara elsevierViewall">While this was not the aim of our study&#44; it important to contextualize our results with those obtained by alternative techniques&#46; Since its introduction by Sigwart in 1994&#44; ASA has been performed in thousands of patients with HOCM with good short-term results&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; there have been no randomized control trials comparing the efficacy and outcomes of percutaneous ASA and surgical myectomy&#46; Several non-randomized comparative studies were recently analyzed in both a meta-analysis &#40;Alam et al&#46;&#44; 2009&#44; involving five studies and 351 patients&#41; and a systematic review &#40;Leonardi et al&#46;&#44; 2010&#44; involving 27 studies and 4094 patients&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> The results show that both therapeutic modalities offer similar significant reductions in LVOT obstruction and symptomatic improvement&#44; as well as similarly low all-cause in-hospital and long-term mortality and sudden cardiac death&#46; Myectomy is associated with a lower risk of complete AV block necessitating permanent pacemaker implantation&#44; although at the cost of a higher risk of stroke and a longer postoperative recovery period&#59; following ASA&#44; a higher number of patients required a second procedure &#40;either repeat ASA or myectomy&#41; because of an unsatisfactory result&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> Therefore&#44; in view of these emerging long-term results&#44; surgery and percutaneous septal ablation should be regarded as alternative treatment options in HOCM&#44; in terms of safety and efficacy&#46; It is prudent to take account of the benefits and drawbacks of each therapeutic method when deciding on treatment for LVOT obstruction&#44; taking into consideration clinical&#44; morphological&#44; and technical aspects&#44; the individual experience of the center and the merit of each treatment modality for the individual patient&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Study limitations</span><p id="par0150" class="elsevierStylePara elsevierViewall">The present study has a retrospective design&#44; and intervened patients were subject to selection bias&#44; which must be considered in the interpretation of its results&#46; Most importantly&#44; the small population analyzed limited the statistical analysis of the results and their extrapolability&#46; Despite these limitations&#44; our study benefits from technical consistency between patients and a careful long-term clinical and echocardiographic follow-up&#44; factors reflected in significant results that are very similar to the published data&#46; Most of all&#44; it was never our intention to analyze a representative population or to reach innovative conclusions&#44; but only to perform and share a critical self-evaluation of our initial practice in this area&#46;</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0155" class="elsevierStylePara elsevierViewall">Percutaneous ASA was shown to be an effective alternative therapy in patients with severe symptomatic HOCM refractory to medical treatment&#46; In this population it was associated with significant acute and long-term falls in LVOT pressure gradient&#44; ventricular septal thickness and mitral regurgitation&#44; accompanied by clear functional improvement in long-term follow-up&#46; However&#44; this invasive technique was not free of procedural and periprocedural complications&#44; underlining the importance of careful patient selection and of the technical expertise of the center&#46; Alcohol septal ablation is still evolving&#44; and it is hoped that refinements in the technique will lead to further improvement in outcomes&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Percutaneous septal ablation by alcohol-induced septal branch occlusion was introduced as a new treatment option in symptomatic patients with hypertrophic obstructive cardiomyopathy &#40;HOCM&#41;&#46; Our aim was to evaluate procedural and long-term clinical and echocardiographic outcomes in patients with HOCM treated by alcohol septal ablation &#40;ASA&#41; at our center&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This single-center retrospective study included 14 consecutive HOCM patients undergoing percutaneous ASA &#40;66&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;1 years&#44; 71&#46;4&#37; female&#41;&#46; At baseline all patients presented persistent symptoms despite optimized medical treatment&#44; left ventricular outflow tract &#40;LVOT&#41; obstruction with a peak gradient &#62;50<span class="elsevierStyleHsp" style=""></span>mmHg&#44; systolic anterior motion of the mitral valve&#44; and ventricular septal thickness &#8805;15<span class="elsevierStyleHsp" style=""></span>mm&#46; ASA was considered successful when the LVOT pressure gradient fell to less than 50&#37; of baseline value&#46; All patients had echocardiographic evaluation at baseline&#44; intraprocedure and at follow-up&#44; and a long-term clinical follow-up &#40;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>38 months&#41; with evaluation of functional class and occurrence of symptoms or cardiovascular events&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Percutaneous ASA achieved a 71&#46;4&#37; acute and 85&#46;7&#37; long-term success rate&#46; Peak LVOT gradient decreased from 104<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>mmHg at baseline to 58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mmHg intraprocedure &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41; and 35<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26<span class="elsevierStyleHsp" style=""></span>mmHg at follow-up &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#59; total gradient decrease was 75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>43<span class="elsevierStyleHsp" style=""></span>mmHg&#46; Ventricular septal thickness and mitral regurgitation also presented significant decreases during follow-up &#40;from 24<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm to 18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>mm&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#44; and from grade 2&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;6 to 1&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; respectively&#41;&#46; A tendency for long-term improvement in NYHA functional class &#40;from 2&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;1 to 1&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;4&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;09&#41; was observed&#46; Procedural complications occurred in 6&#46;7&#37; of patients&#59; two deaths and one transient ischemic attack occurred in-hospital&#44; but no long-term clinical events were recorded&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Percutaneous ASA is an effective treatment for symptomatic patients with HOCM&#44; obtaining a marked decrease in LVOT pressure gradient and symptomatic improvement&#46; Despite the occurrence of a significant number of procedural complications&#44; the favorable long-term outcomes underline the potential of ASA as a percutaneous alternative to surgical myectomy&#46;</p>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A abla&#231;&#227;o septal percut&#226;nea por indu&#231;&#227;o alco&#243;lica da oclus&#227;o de ramos coron&#225;rios septais foi introduzida como uma nova op&#231;&#227;o terap&#234;utica em doentes com cardiomiopatia hipertr&#243;fica obstrutiva &#40;HOCM&#41; sintom&#225;tica&#46; O nosso objetivo foi a avalia&#231;&#227;o dos resultados cl&#237;nicos e ecocardiogr&#225;ficos agudos e a longo-prazo em doentes com HOCM tratados por abla&#231;&#227;o septal alco&#243;lica &#40;ASA&#41; no nosso centro&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo monoc&#234;ntrico&#44; retrospetivo incluindo 14 doentes consecutivos com HOCM submetidos a ASA percut&#226;nea &#40;66&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;1 anos&#44; 71&#44;4&#37; sexo feminino&#41;&#46; Todos os doentes apresentavam basalmente sintomas persistentes apesar de terap&#234;utica m&#233;dica otimizada&#44; obstru&#231;&#227;o da c&#226;mara de sa&#237;da do ventr&#237;culo esquerdo &#40;LVOT&#41; com gradiente m&#225;ximo &#62;50<span class="elsevierStyleHsp" style=""></span>mmHg&#44; movimento sist&#243;lico anterior da v&#225;lvula mitral e espessura do septo interventricular &#8805;15<span class="elsevierStyleHsp" style=""></span>mm&#46; A ASA foi considerada bem sucedida quando o gradiente do LVOT diminuiu para menos de 50&#37; do valor inicial&#46; Todos os doentes foram submetidos a avalia&#231;&#227;o cl&#237;nica e ecocardiogr&#225;fica basal&#44; intraprocedimento e durante o seguimento&#44; com avalia&#231;&#227;o da classe funcional e ocorr&#234;ncia de sintomas ou eventos cardiovasculares a longo-prazo &#40;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>38 meses&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A ASA percut&#226;nea obteve uma taxa de sucesso de 71&#44;4&#37; e 85&#44;7&#37;&#44; respetivamente aguda e a longo-prazo&#46; O gradiente m&#225;ximo do LVOT diminuiu de 104<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>mmHg basais para 58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mmHg intraprocedimento &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41; e 35<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26<span class="elsevierStyleHsp" style=""></span>mmHg a longo-prazo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#59; o decr&#233;scimo total do gradiente foi de 75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>43<span class="elsevierStyleHsp" style=""></span>mmHg&#46; Tamb&#233;m a espessura do septo interventricular e a regurgita&#231;&#227;o mitral apresentaram uma diminui&#231;&#227;o significativa durante o seguimento &#40;de 24<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm para 18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>mm&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#44; e de grau 2&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;6 para 1&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;5&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#44; respetivamente&#41;&#46; Uma tend&#234;ncia para a melhoria a longo-prazo da classe funcional NYHA &#40;de 2&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;1 to 1&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;4&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;09&#41; foi observada&#46; Complica&#231;&#245;es do procedimento ocorreram em 6&#44;7&#37; dos doentes&#59; duas mortes e um acidente isqu&#233;mico transit&#243;rio ocorreram no hospital&#44; n&#227;o se registando eventos cl&#237;nicos a longo-prazo&#46;</p> <span class="elsevierStyleSectionTitle">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A ASA percut&#226;nea &#233; uma terap&#234;utica eficaz para doentes sintom&#225;ticos com HOCM&#44; obtendo uma acentuada diminui&#231;&#227;o do gradiente de press&#227;o do LVOT e melhoria sintom&#225;tica&#46; Apesar da ocorr&#234;ncia de um n&#250;mero significativo de complica&#231;&#245;es periprocedimento&#44; o favor&#225;vel progn&#243;stico a longo-prazo sublinha o potencial da ASA como uma alternativa percut&#226;nea &#224; miectomia cir&#250;rgica&#46;</p>"
      ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Angiographic demonstration of alcohol septal ablation technique&#46; Left coronary angiography shows the target septal branch &#40;arrow&#41;&#59; an angioplasty guidewire is already inserted inside the septal branch &#40;A&#41;&#46; Optimal positioning of the balloon catheter &#40;arrow&#41; in the proximal part of the septal artery without compromise of the left anterior descending artery &#40;B&#41;&#46; Injection of angiographic contrast dye through the central lumen of the inflated balloon catheter &#40;arrow&#41; determines the supply area of the septal branch and excludes leakage into the left anterior descending artery or other coronary vessels &#40;C&#41;&#46; Final demonstration of the septal artery stump &#40;arrow&#41; after alcohol-induced occlusion &#40;D&#41;&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Myocardial contrast echocardiography during alcohol septal ablation&#46; First&#44; the anatomy of the heart is presented and the target septal area is identified &#40;A&#41;&#46; Injection of echocardiographic contrast into the target septal branch opacifies the basal part of the septum&#44; verifying the optimal choice of septal branch &#40;B&#41;&#46; A more sustained opacification of the basal septum after alcohol injection signifies a good alcohol depot &#40;C&#41;&#46;</p>"
        ]
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        "mostrarFloat" => true
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic evolution of resting left ventricular outflow tract peak gradient in patients undergoing percutaneous alcohol septal ablation&#46; LVOT&#58; left ventricular outflow tract&#46;</p>"
        ]
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      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Overall survival after percutaneous alcohol septal ablation&#46;</p>"
        ]
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      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Evolution of New York Heart Association &#40;NYHA&#41; class from baseline to end of follow-up in patients undergoing alcohol septal ablation&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Values are presented as number &#40;&#37;&#41; or as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#44; unless otherwise stated&#46; CCS&#58; Canadian Cardiovascular Society&#59; HCM&#58; hypertrophic cardiomyopathy&#59; ICD&#58; implantable cardioverter-defibrillator&#59; LV&#58; left ventricular&#59; LVOT&#58; left ventricular outflow tract&#59; NYHA&#58; New York Heart Association&#59; PPM&#58; permanent pacemaker&#59; SCD&#58; sudden cardiac death&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Age&#44; years&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">66&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female gender&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">10 &#40;71&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">11 &#40;78&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CCS class III or IV angina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;42&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3 &#40;21&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ventricular arrhythmias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Comorbidities and medical history</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Arterial hypertension&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">7 &#40;50&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2 &#40;14&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Coronary artery disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;6&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cerebrovascular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;14&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Atrial fibrillation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;28&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Previous PPM&#47;ICD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Family history of HCM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Family history of SCD&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Beta-blockers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;78&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Calcium channel antagonists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;50&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Disopyramide&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ventricular septal thickness&#44; mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LV posterior wall thickness&#44; mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LV end-diastolic diameter&#44; mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LV ejection fraction &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Resting LVOT pressure gradient&#44; mmHg <a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">104<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>40&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Provocable LVOT pressure gradient&#44; mmHg <a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mitral regurgitation&#44; grade&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Organic mitral valve disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">LV end-diastolic diameter&#44; mm&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Outcome of alcohol septal ablation for obstructive hypertrophic cardiomyopathy"
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        "titulo" => "Acknowledgment"
        "texto" => "<p id="par0165" class="elsevierStylePara elsevierViewall">Dr&#46; S&#237;lvio Leal wishes to express his gratitude to the <span class="elsevierStyleGrantSponsor">Portuguese Society of Cardiolog</span>y&#44; from whom he was receiving a training grant at the time this article was written&#46;</p>"
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2012.04.011

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Year/Month	Html	Pdf	Total

2024 November	8	6	14
2024 October	157	42	199
2024 September	48	32	80
2024 August	132	37	169
2024 July	31	31	62
2024 June	35	25	60
2024 May	50	26	76
2024 April	38	21	59
2024 March	42	20	62
2024 February	34	23	57
2024 January	32	30	62
2023 December	62	26	88
2023 November	51	36	87
2023 October	33	16	49
2023 September	22	33	55
2023 August	25	13	38
2023 July	33	11	44
2023 June	26	16	42
2023 May	46	28	74
2023 April	25	11	36
2023 March	40	29	69
2023 February	24	26	50
2023 January	28	15	43
2022 December	43	33	76
2022 November	45	34	79
2022 October	40	27	67
2022 September	37	33	70
2022 August	31	38	69
2022 July	28	41	69
2022 June	32	28	60
2022 May	30	44	74
2022 April	54	42	96
2022 March	48	46	94
2022 February	29	45	74
2022 January	46	42	88
2021 December	26	39	65
2021 November	38	47	85
2021 October	59	57	116
2021 September	33	32	65
2021 August	38	42	80
2021 July	30	39	69
2021 June	28	39	67
2021 May	32	54	86
2021 April	50	76	126
2021 March	46	23	69
2021 February	97	14	111
2021 January	33	11	44
2020 December	43	17	60
2020 November	34	15	49
2020 October	23	18	41
2020 September	54	23	77
2020 August	26	8	34
2020 July	43	14	57
2020 June	38	19	57
2020 May	33	9	42
2020 April	35	11	46
2020 March	39	16	55
2020 February	111	41	152
2020 January	26	8	34
2019 December	42	7	49
2019 November	27	12	39
2019 October	715	4	719
2019 September	60	10	70
2019 August	38	7	45
2019 July	31	9	40
2019 June	36	25	61
2019 May	43	11	54
2019 April	27	14	41
2019 March	88	9	97
2019 February	83	9	92
2019 January	54	9	63
2018 December	51	10	61
2018 November	115	11	126
2018 October	296	20	316
2018 September	80	9	89
2018 August	81	5	86
2018 July	91	4	95
2018 June	114	7	121
2018 May	117	9	126
2018 April	87	1	88
2018 March	105	5	110
2018 February	76	4	80
2018 January	171	3	174
2017 December	250	10	260
2017 November	98	17	115
2017 October	57	20	77
2017 September	48	17	65
2017 August	61	15	76
2017 July	46	9	55
2017 June	63	8	71
2017 May	96	10	106
2017 April	63	6	69
2017 March	59	30	89
2017 February	64	3	67
2017 January	48	9	57
2016 December	78	15	93
2016 November	49	2	51
2016 October	41	12	53
2016 September	25	4	29
2016 August	9	6	15
2016 July	21	4	25
2016 June	21	1	22
2016 May	18	1	19
2016 April	21	3	24
2016 March	41	3	44
2016 February	61	16	77
2016 January	45	8	53
2015 December	42	4	46
2015 November	31	8	39
2015 October	43	6	49
2015 September	31	5	36
2015 August	55	7	62
2015 July	50	5	55
2015 June	30	3	33
2015 May	31	7	38
2015 April	41	14	55
2015 March	16	2	18
2015 February	21	3	24
2015 January	45	7	52
2014 December	52	5	57
2014 November	24	8	32
2014 October	29	6	35
2014 September	23	3	26
2014 August	22	6	28
2014 July	38	9	47
2014 June	23	4	27
2014 May	29	8	37
2014 April	16	2	18
2014 March	35	12	47
2014 February	44	10	54
2014 January	33	10	43
2013 December	31	6	37
2013 November	48	9	57
2013 October	54	8	62
2013 September	46	15	61
2013 August	77	16	93
2013 July	52	12	64
2013 June	22	9	31
2013 May	34	6	40
2013 April	52	15	67
2013 March	34	8	42
2013 February	53	19	72
2013 January	61	13	74
2012 December	43	9	52
2012 November	31	11	42
2012 October	5	10	15
2012 September	6	2	8

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