OBJECTIVES
To review our institution's experience with patients who failed to benefit from septal
artery ablation, which necessitated subsequent septal myectomy, and to examine reasons
for ablation failure and outcome of myectomy after ablation.
PATIENTS AND METHODS
Of 550 patients who underwent septal myectomy at Mayo Clinic Rochester between January
1, 1999, and December 31, 2006, 16 (3%) had had a total of 22 previous septal artery
ablations. This subset of 16 patients was analyzed and compared with a reference group
of 120 patients whose septal artery ablations were performed at our institution during
this period. Angiograms obtained during septal ablation were available for 13 (81%)
of 16 patients in this series and were reviewed by 2 interventional cardiologists
(R.A.N. and S.R.O.). These cardiologists also reviewed preoperative and postoperative
echocardiography data, hospital course, and follow-up data to compile a list of characteristics
that could have contributed to failed ablation.
RESULTS
The median age of the patients at operation was 65 years (interquartile range [IQR],
52-72 years), and interval between ablation and myectomy was 409 days (IQR, 162-568
days). Angiograms revealed 2 failed procedures secondary to technical error. One patient
had a relatively large first septal perforator with a large resting gradient. In 10
patients no septal perforators supplying the proximal septum were identified. Postoperatively,
mitral regurgitation decreased from 3.00 to 1.00 (P<.001), and left ventricular outflow tract gradient decreased from 75 mm Hg to 0 mm
Hg (IQR, 0-29 mm Hg; P<.001). Two patients died after surgery: 1 patient developed multiple-organ system
failure on postoperative day 7, and 1 patient developed arrhythmia on postoperative
day 21. Patients with previous septal artery ablation were older (P=.04), were more likely to have preoperative permanent pace-makers or implantable
cardioverter-defibrillators (P=.05), were more likely to require postoperative pacemaker placement (P<.001), and had higher operative mortality (P<.001) than control patients. Fourteen patients survived the early recovery phase;
9 were followed up at a median of 1.88 years (IQR, 306 days to 3.3 years). All patients'
symptoms improved. Median gradient of the left ventricular outflow tract was 13 mm
Hg (IQR, 0-15 mm Hg) at follow-up with mild to moderate (1.6) mitral regurgitation.
CONCLUSION
Septal myectomy performed after failed ablation improves gradient and provides excellent
relief of symptoms but is associated with a higher incidence of morbidity and mortality.
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Article Info
Footnotes
This work was presented in part at the American Heart Association Scientific Sessions 2006; November 13, 2006; Chicago, IL.
Identification
Copyright
© 2007 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
