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| {{Hypertrophic cardiomyopathy}} | | {{Hypertrophic cardiomyopathy}} |
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| '''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org]; {{AOEIC}} [[Cafer Zorkun, M.D.]] [mailto:zorkun@perfuse.org]; Caitlin J. Harrigan [mailto:charrigan@perfuse.org]; Martin S. Maron, M.D.; Barry J. Maron, M.D.; {{LG}} | | '''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; {{AOEIC}} [[Cafer Zorkun, M.D.]] [mailto:zorkun@perfuse.org]; Caitlin J. Harrigan [mailto:charrigan@perfuse.org]; Martin S. Maron, M.D.; Barry J. Maron, M.D.; {{LG}} |
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| ==Alcohol septal ablation== | | ==2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy (DO NOT EDIT)<ref name="pmid22075469">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=e212–60 |year=2011 |month=December |pmid=22075469 |doi=10.1016/j.jacc.2011.06.011 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02275-3 |accessdate=2011-12-19}}</ref>== |
| ===Overview===
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| [[Alcohol septal ablation]] is a percutaneous technique that involves injection of alcohol into the first septal perferator of the [[coronary circulation|left anterior descending artery]]. This is a technique with results similar to the surgical septal myectomy procedure but is less invasive, since it does not involve general anaesthesia and opening of the chest wall and pericardium (which are done in a septal myomectomy). In a select population with symptoms secondary to a high outflow tract gradient, alcohol septal ablation can reduce the symptoms of HCM.<ref name="pmid11886323">{{cite journal| author=Maron BJ| title=Hypertrophic cardiomyopathy: a systematic review. | journal=JAMA | year= 2002 | volume= 287 | issue= 10 | pages= 1308-20 | pmid=11886323 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11886323 }} </ref><ref name="pmid7671349">{{cite journal| author=Wigle ED, Rakowski H, Kimball BP, Williams WG| title=Hypertrophic cardiomyopathy. Clinical spectrum and treatment. | journal=Circulation | year= 1995 | volume= 92 | issue= 7 | pages= 1680-92 | pmid=7671349 | doi= | pmc= | url= }} </ref><ref name="Brilakis and Nishimura 2003">Brilakis ES, Nishimura RA. Severe pulmonary hypertension in a patient with hypertrophic cardiomyopathy: response to alcohol septal ablation. ''[[Heart (journal)|Heart]]''. 2003 Jul; '''89'''(7):790. ([http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12807862 Medline abstract])</ref> When performed properly, an alcohol septal ablation induces a controlled [[myocardial infarction|heart attack]], in which the portion of the interventricular septum that involves the left ventricular outflow tract is infarcted and will contract into a scar.
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| ===History=== | | ===Septal Reduction Therapy (DO NOT EDIT)<ref name="pmid22075469">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=e212–60 |year=2011 |month=December |pmid=22075469 |doi=10.1016/j.jacc.2011.06.011 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02275-3 |accessdate=2011-12-19}}</ref>=== |
| Alcohol septal ablation was first performed in Britain at the [[Royal Brompton Hospital]] by Ulrich Sigwart in 1994. Since that time, it has quickly gained favor among physicians and patients alike due to its minimally-invasive nature, avoiding general anesthesia, lengthy recuperation and other complications associated with open heart surgery (septal myectomy).
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| === Technique === | | {|class="wikitable" |
| Alcohol septal ablation is performed in the cardiac catheterization laboratory, and should only be performed by interventional cardiologists with specific training in the procedure. As such, it is only available in a few institutions. The technique is similar to coronary angioplasty, and utilizes similar equipment. Using wires and balloons to localize the septal artery feeding the diseased muscle, a small amount of absolute alcohol is infused into the artery to produce a small heart attack. Patients typically experience mild chest discomfort during the procedure, which takes approximately 30 minutes to complete. Analesics and mild sedatives are administered as needed. Patients typically are maintained in the hospital for three to four days to monitor for any complications, including need for permanent pacemaker in 5-10%.
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| | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] |
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| ===Efficacy and Procedural Success=== | | |- |
| Relief of obstruction is noted immediately in the majority of appropriately selected patients. Clinical success is defined as a 50% or more reduction in peak gradient across the outflow tract, predicting continued improvement in gradient and cardiac remodeling over the ensuing 1 to 2 years. Over 90% of patients experience a successful procedure, with improvement in outflow tract gradient and [[mitral regurgitation]]. Patients typically report progressive reduction in symptoms, including improved [[shortness of breath]], [[lightheadedness]] and [[chest pain]].
| | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Septal reduction therapy should be performed only by experienced operators in the context of a comprehensive [[HCM]] clinical program and only for the treatment of eligible patients with severe [[Hypertrophic cardiomyopathy medical treatment|drug-refractory symptoms]] and LVOT obstruction<ref name="pmid18435964">{{cite journal |author=van der Lee C, Scholzel B, ten Berg JM, ''et al.'' |title=Usefulness of clinical, echocardiographic, and procedural characteristics to predict outcome after percutaneous transluminal septal myocardial ablation |journal=Am. J. Cardiol. |volume=101 |issue=9 |pages=1315–20 |year=2008 |month=May |pmid=18435964 |doi=10.1016/j.amjcard.2008.01.003 |url=}}</ref>. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> |
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| ===Follow-Up===
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| Serial echocardiograms are routinely obtained to follow the cardiac remodeling over time, and document reduction in outflow tract gradient.
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| ===Comparison to Myectomy===
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| Non-randomized data from the Netherlands suggests caution in the utilization of alcohol septal ablation, which may be inferior to surgical myectomy <ref name="pmid20332420">{{cite journal |author=Ten Cate FJ, Soliman OI, Michels M, Theuns DA, de Jong PL, Geleijnse ML, Serruys PW |title=Long-Term Outcome of Alcohol Septal Ablation in Patients with Obstructive Hypertrophic Cardiomyopathy: A Word of Caution |journal=Circulation. Heart Failure |volume= |issue= |pages= |year=2010 |month=March |pmid=20332420 |doi=10.1161/CIRCHEARTFAILURE.109.862359 |url=http://circheartfailure.ahajournals.org/cgi/pmidlookup?view=long&pmid=20332420 |issn=}}</ref>. The outcomes (the risk of cardiac death and aborted sudden cardiac death including appropriate cardioverter-defibrillator discharges for fast ventricular tachycardia/ventricular fibrillation) in 91 consecutive alcohol septal ablation patients were compared with 40 patients who underwent septal myectomy. The 1-, 5-, and 8-year event free survival was 96%, 86%, and 67%, respectively in the alcohol septal ablation patients which was poorer than the 100%, 96%, and 96%, event free rates in the myectomy patients over 6.6±2.7 years (P=0.01). Stated differently, the alcohol septal ablation patients faced a 5-fold increase in the risk of the primary endpoint on an annual basis (4.4% versus 0.9%) even when adjustments were made in a propensity adjusted multivariable model (p=0.02). Based upon non-randomized data, myectomy may be prefferable to alcohol septal ablation.
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| It is important to note that patients who fail to respond to alcohol septal ablation may still be candidates for surgical myectomy. Likewise, patients who fail surgical myectomy may still respond to alcohol septal ablation.
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| ===2011 ACCF/AHA Guideline Recommendations: Alcohol Septal Ablation <ref name="pmid22075468">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=2703–38 |year=2011 |month=December |pmid=22075468 |doi=10.1016/j.jacc.2011.10.825 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)04383-X |accessdate=2011-12-19}}</ref><ref name="pmid22075469">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=e212–60 |year=2011 |month=December |pmid=22075469 |doi=10.1016/j.jacc.2011.06.011 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02275-3 |accessdate=2011-12-19}}</ref>===
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| {{cquote|
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| ====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]====
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| '''1.''' Consultation with centers experienced in performing both surgical [[septal myectomy]] and alcohol septal ablation is reasonable when discussing treatment options for eligible patients with HCM with severe drug-refractory symptoms and LVOT obstruction. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''2.''' When surgery is contraindicated or the risk is considered unacceptable because of serious comorbidities or advanced age, alcohol septal ablation, when performed in experienced centers, can be beneficial in eligible adult patients with [[HCM]] with LVOT obstruction and severe [[Hypertrophic cardiomyopathy medical treatment|drug-refractory symptoms]] (usually [[New york heart association functional classification#New York Heart Association Functional Classification (NYHA)|NYHA functional classes III or IV]]).(62,153,277–281) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
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| ====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]====
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| '''1.''' Alcohol septal ablation, when performed in experienced centers, may be considered as an alternative to [[surgical myectomy]] for eligible adult patients with [[HCM]] with severe [[Hypertrophic cardiomyopathy medical treatment|drug-refractory symptoms]] and LVOT obstruction when, after a balanced and thorough discussion, the patient expresses a preference for septal ablation.(153,273,278,280,281) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
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| '''2.''' The effectiveness of alcohol septal ablation is uncertain in patients with [[HCM]] with marked (i.e., >30 mm) septal hypertrophy, and therefore the procedure is generally discouraged in such patients. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| ====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)====
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| '''1.''' Alcohol septal ablation should not be done in patients with [[HCM]] with concomitant disease that independently warrants surgical correction (e.g., [[CABG|coronary artery bypass grafting for CAD]], [[mitral valve repair]] for ruptured chordae) in whom [[surgical myectomy]] can be performed as part of the operation. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''2.''' Alcohol septal ablation should not be done in patients with [[HCM]] who are less than 21 years of age and is discouraged in adults less than 40 years of age if [[surgical myectomy|myectomy]] is a viable option. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''}}
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| ==Septal Myectomy==
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| [[Septal myectomy]] is a [[cardiac surgery|surgical]] treatment for [[hypertrophic cardiomyopathy]] (HCM). Septal myectomies have been successfully performed for more than 25 years.
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| ====Outcomes====
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| Septal myectomy is associated with a low perioperative mortality and a high late survival rate. A study at the [[Mayo Clinic]] found surgical myectomy performed to relieve outflow obstruction and severe symptoms in HCM was associated with long-term survival equivalent to that of the general population, and superior to obstructive HCM without operation. The results are shown below:<ref name="Ommen 2005">{{cite journal | author = Ommen S, Maron B, Olivotto I, Maron M, Cecchi F, Betocchi S, Gersh B, Ackerman M, McCully R, Dearani J, Schaff H, Danielson G, Tajik A, Nishimura R | title = Long-term effects of surgical septal myectomy on survival in patients with obstructive hypertrophic cardiomyopathy | journal = J Am Coll Cardiol | volume = 46 | issue = 3 | pages = 470-6 | year = 2005 | id = PMID 16053960}}</ref>
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| | | |colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm) |
| <center>
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| {| border="0"
| | |bgcolor="LightCoral"| <nowiki>"</nowiki>'''1.''' Septal reduction therapy should not be done for adult patients with [[HCM]] who are asymptomatic with normal exercise tolerance or whose symptoms are controlled or minimized on [[Hypertrophic cardiomyopathy medical treatment|optimal medical therapy]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> |
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| {| class="wikitable"
| | |bgcolor="LightCoral"| <nowiki>"</nowiki>'''2.''' Septal reduction therapy should not be done unless performed as part of a program dedicated to the longitudinal and multidisciplinary care of patients with [[HCM]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> |
| |+ Survival (all-cause mortality) *
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| |-
| | |bgcolor="LightCoral"| <nowiki>"</nowiki>'''3.''' [[Mitral valve replacement]] for relief of LVOT obstruction should not be performed in patients with [[HCM]] in whom septal reduction therapy is an option. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> |
| ! Years
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| ! With surgery
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| ! Without surgery
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| |-
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| | 1
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| | 98%
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| | 90%
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| |-
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| | 5
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| | 96%
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| | 79%
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| |-
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| | 10
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| | 83%
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| | 61%
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| |}
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| {| class="wikitable"
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| |+ Survival (HCM-related death)
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| |-
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| ! Years
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| ! With surgery
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| ! Without surgery
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| |-
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| | 1
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| | 99%
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| | 94%
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| |-
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| | 5
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| | 98%
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| | 89%
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| |-
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| | 10
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| | 95%
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| | 73%
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| |}
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| {| class="wikitable"
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| |+ Survival (sudden cardiac death)
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| |-
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| ! Years
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| ! With surgery
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| ! Without surgery
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| |-
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| | 1
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| | 100%
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| | 97%
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| |-
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| | 5
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| | 99%
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| | 93%
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| |-
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| | 10
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| | 99%
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| | 89%
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| |}
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| |} | | |} |
| <nowiki>*</nowiki> Includes 0.8% operative mortality.
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| </center>
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| ====Comparison with alcohol ablation====
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| Either [[alcohol septal ablation]] or myectomy offers substantial clinical improvement for patients with [[hypertrophic obstructive cardiomyopathy]].
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| Hemodynamic resolution of the obstruction and its sequelae is more complete with myectomy.<ref name="Ralph-Edwards 2005">{{cite journal | author = Ralph-Edwards A, Woo A, McCrindle B, Shapero J, Schwartz L, Rakowski H, Wigle E, Williams W | title = Hypertrophic obstructive cardiomyopathy: comparison of outcomes after myectomy or alcohol ablation adjusted by propensity score | journal = J Thorac Cardiovasc Surg | volume = 129 | issue = 2 | pages = 351-8 | year = 2005 | id = PMID 15678046}}</ref>
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| ===2011 ACCF/AHA Guideline Recommendations: Septal Myectomy <ref name="pmid22075468">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=2703–38 |year=2011 |month=December |pmid=22075468 |doi=10.1016/j.jacc.2011.10.825 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)04383-X |accessdate=2011-12-19}}</ref><ref name="pmid22075469">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=e212–60 |year=2011 |month=December |pmid=22075469 |doi=10.1016/j.jacc.2011.06.011 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02275-3 |accessdate=2011-12-19}}</ref>===
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| ====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]====
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| '''1.''' Consultation with centers experienced in performing both surgical [[septal myectomy]] and alcohol septal ablation is reasonable when discussing treatment options for eligible patients with HCM with severe drug-refractory symptoms and LVOT obstruction. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''2.''' [[septal myectomy|Surgical septal myectomy]], when performed in experienced centers, can be beneficial and is the first consideration for the majority of eligible patients with [[HCM]] with severe [[Hypertrophic cardiomyopathy medical treatment|drug-refractory symptoms]] and LVOT obstruction.(61,62,155,273–275) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
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| '''3.''' [[septal myectomy|Surgical septal myectomy]], when performed at experienced
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| centers, can be beneficial in symptomatic children with [[HCM]] and severe resting obstruction (>50 mm Hg) for whom standard medical therapy has failed.(276) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''}}
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| ==Ventricular pacing==
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| The use of a [[artificial pacemaker|pacemaker]] has been advocated in a subset of individuals, in order to cause asynchronous contraction of the left ventricle. Since the pacemaker activates the interventricular septum before the left ventricular free wall, the gradient across the left ventricular outflow tract may decrease. The AV interval must be shortened to do this, but not at the expense of diastolic filling. This form of treatment has been shown to provide less relief of symptoms and less of a reduction in the left ventricular outflow tract gradient when compared to surgical myectomy
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| <ref name="Ommen, Nishimura et al 1999">Ommen SR, Nishimura RA, Squires RW, Schaff HV, Danielson GK, Tajik AJ. Comparison of dual-chamber pacing versus septal myectomy for the treatment of patients with hypertropic obstructive cardiomyopathy: a comparison of objective hemodynamic and exercise end points. ''[[Journal of the American College of Cardiology|J Am Coll Cardiol]]''. 1999 Jul; '''34'''(1):191–6. ([http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10400010 Medline abstract])</ref>. Dual chamber pacing does not decrease the risk of [[sudden cardiac death]] in these patients.
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| ===2011 ACCF/AHA Guideline Recommendations: Pacing <ref name="pmid22075468">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=2703–38 |year=2011 |month=December |pmid=22075468 |doi=10.1016/j.jacc.2011.10.825 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)04383-X |accessdate=2011-12-19}}</ref><ref name="pmid22075469">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=e212–60 |year=2011 |month=December |pmid=22075469 |doi=10.1016/j.jacc.2011.06.011 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02275-3 |accessdate=2011-12-19}}</ref>===
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| ====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]====
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| '''1.''' In patients with [[HCM]] who have had a dual-chamber device implanted for non-HCM indications, it is reasonable to consider a trial of dual-chamber atrial-ventricular pacing (from the right ventricular apex) for the relief of symptoms attributable to LVOT obstruction.(292,294,295,366) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
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| ====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]====
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| '''1.''' Permanent pacing may be considered in medically refractory symptomatic patients with obstructive HCM who are suboptimal candidates for septal reduction therapy.(283,292,294,295,366) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
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| ====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)====
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| '''1.''' Permanent pacemaker implantation for the purpose of reducing gradient should not be performed in patients with HCM who are asymptomatic or whose symptoms are medically controlled.(283,284,367) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''2.''' Permanent pacemaker implantation should not be performed as a first-line therapy to relieve symptoms in medically refractory symptomatic patients with HCM and LVOT obstruction who are candidates for septal reduction.(283,284,367) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''}}
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| ===2007 ESC Guidelines- Cardiac Pacing in HCM <ref name="pmid17726043">{{cite journal| author=Vardas PE, Auricchio A, Blanc JJ, Daubert JC, Drexler H, Ector H et al.| title=Guidelines for cardiac pacing and cardiac resynchronization therapy. The Task Force for Cardiac Pacing and Cardiac Resynchronization Therapy of the European Society of Cardiology. Developed in collaboration with the European Heart Rhythm Association. | journal=Europace | year= 2007 | volume= 9 | issue= 10 | pages= 959-98 | pmid=17726043 | doi=10.1093/europace/eum189 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17726043 }} </ref>===
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| ====[[European society of cardiology#Classes of Recommendations|Class IIa]]====
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| '''1.''' Symptomatic [[bradycardia]] due to [[Beta blockers|beta-blockade]] when alternative therapies are unacceptable. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''
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| ====[[European society of cardiology#Classes of Recommendations|Class IIb]]====
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| '''1.''' Patients with drug refractory hypertrophic cardiomyopathy with significant resting or provoked [[LVOT]] gradient <ref name="pmid1350522">{{cite journal| author=Fananapazir L, Cannon RO, Tripodi D, Panza JA| title=Impact of dual-chamber permanent pacing in patients with obstructive hypertrophic cardiomyopathy with symptoms refractory to verapamil and beta-adrenergic blocker therapy. | journal=Circulation | year= 1992 | volume= 85 | issue= 6 | pages= 2149-61 | pmid=1350522 | doi= | pmc= | url= }} </ref><ref name="pmid7994815">{{cite journal| author=Fananapazir L, Epstein ND, Curiel RV, Panza JA, Tripodi D, McAreavey D| title=Long-term results of dual-chamber (DDD) pacing in obstructive hypertrophic cardiomyopathy. Evidence for progressive symptomatic and hemodynamic improvement and reduction of left ventricular hypertrophy. | journal=Circulation | year= 1994 | volume= 90 | issue= 6 | pages= 2731-42 | pmid=7994815 | doi= | pmc= | url= }} </ref><ref name="pmid9458416">{{cite journal| author=Kappenberger L, Linde C, Daubert C, McKenna W, Meisel E, Sadoul N et al.| title=Pacing in hypertrophic obstructive cardiomyopathy. A randomized crossover study. PIC Study Group. | journal=Eur Heart J | year= 1997 | volume= 18 | issue= 8 | pages= 1249-56 | pmid=9458416 | doi= | pmc= | url= }} </ref> and contraindications for [[Hypertrophic cardiomyopathy interventional cardiology#Alcohol septal ablation|septal ablation]] or [[septal mectomy|myectomy]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''
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| ====[[European society of cardiology#Classes of Recommendations|Class III]]====
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| '''1.''' Asymptomatic patients. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''
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| '''2.''' Symptomatic patients who do not have [[LVOT]] obstruction. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''}}
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| ==Automatic Implantable Cardiac Defibrillator (AICD) placement==
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| The role of AICD (automatic implantable cardiac defibrillator) placement in HCM is controversial. It offers the best potential benefit for survival and should probably be implanted in survivors of SCD and those deemed at high risk by clinical parameters. Nonetheless, the impact on prognosis is unclear because tachyarrhythmias may not always be the mechanism for syncope and sudden death. In addition, older patients may be self-selected “survivors” that stand to gain less from ICD placement. One recent retrospective study showed that at an average follow-up of 128 patients at 3.1 years, 23 percent had shocks for VT (ventricular tachycardia) and 25% had inappropriate shocks. Of those receiving the ICD prophylactically, 5% were shocked per year. This study did not evaluate the role of clinical predictors, evaluate total mortality and was a non-randomized retrospective design that does not establish the need for ICD placement in all patients with HCM or superiority to amiodarone therapy.
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| ==2011 ACCF/AHA Guideline Recommendations: Invasive Therapies==
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| <ref name="pmid22075468">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=2703–38 |year=2011 |month=December |pmid=22075468 |doi=10.1016/j.jacc.2011.10.825 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)04383-X |accessdate=2011-12-19}}</ref><ref name="pmid22075469">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=e212–60 |year=2011 |month=December |pmid=22075469 |doi=10.1016/j.jacc.2011.06.011 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02275-3 |accessdate=2011-12-19}}</ref>
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| {{cquote|
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| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
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| '''1.''' Septal reduction therapy should be performed only by experienced operators in the context of a comprehensive [[HCM]] clinical program and only for the treatment of eligible patients with severe [[Hypertrophic cardiomyopathy medical treatment|drug-refractory symptoms]] and LVOT obstruction.† (272) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| ====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)====
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| '''1.''' Septal reduction therapy should not be done for adult patients with [[HCM]] who are asymptomatic with normal exercise tolerance or whose symptoms are controlled or minimized on [[Hypertrophic cardiomyopathy medical treatment|optimal medical therapy]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''2.''' Septal reduction therapy should not be done unless performed as part of a program dedicated to the longitudinal and multidisciplinary care of patients with [[HCM]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''3.''' [[Mitral valve replacement]] for relief of LVOT obstruction should
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| not be performed in patients with [[HCM]] in whom septal reduction therapy is an option. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''}}
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| ==Guideline Resources== | | ==Sources== |
| *[http://circ.ahajournals.org/content/117/21/e350.full.pdf ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities] <ref name="Epstein"> Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Circulation. 2008; 117: 2820–2840. PMID 18483207 </ref> | | *[http://circ.ahajournals.org/content/117/21/e350.full.pdf ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities] <ref name="Epstein"> Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Circulation. 2008; 117: 2820–2840. PMID 18483207 </ref> |
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