Septal reduction therapy tied to reduced readmissions for HF
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In patients with obstructive hypertrophic cardiomyopathy, septal reduction therapy was associated with reduced risk for HF readmissions, researchers reported in the Journal of the American College of Cardiology.
When comparing the types of septal reduction therapy, the researchers found that septal myectomy was associated with fewer redo procedures and better long-term survival compared with alcohol septal ablation.
Data were derived from Mentias A, et al. J Am Coll Cardiol. 2023;doi:10.1016/j.jacc.2022.10.027.
Amgad Mentias, MD, MSc, a clinical cardiologist in the Tomsich Family Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, and colleagues analyzed 5,679 Medicare beneficiaries older than 65 years with obstructive hypertrophic cardiomyopathy who underwent septal reduction therapy between 2013 and 2019. The cohort included 3,680 patients who had septal myectomy (mean age, 73 years; 67% women) and 1,999 patients who had alcohol septal ablation (mean age, 75 years; 71% women).
The researchers used overlap propensity score weighting to adjust for differences in baseline characteristics.
At 4 years, there was no difference between the septal myectomy group and the alcohol septal ablation group in mortality (HR = 0.87; 95% CI, 0.74-1.03; P = .1), Mentias and colleagues found.
However, in a landmark analysis, beyond 2 years of follow-up, septal myectomy was associated with reduced risk for mortality compared with alcohol septal ablation (HR = 0.72; 95% CI, 0.6-0.87; P < .001). There was no difference between the groups during the first 2 years of follow-up.
Short-term outcomes favored alcohol septal ablation, which was associated with lower rates of in-hospital mortality, in-hospital stroke, in-hospital acute kidney injury with new dialysis and 30-day mortality compared with septal myectomy (P < .001 for all).
Septal myectomy was associated with lower rates of redo procedures compared with alcohol septal ablation (HR = 0.1; 95% CI, 0.07-0.15; P < .001), according to the researchers.
HF readmission burden reduced
Both procedures were associated with lower rates of HF readmission burden after the procedure compared with 1 year before the procedure (RR for septal myectomy = 0.65; 95% CI, 0.57-0.73; P < .001; RR for alcohol septal ablation = 0.55; 95% CI, 0.49-0.62; P < .001; P for interaction = .4), the researchers wrote.
High-volume centers produced better outcomes than lower-volume centers, but approximately 70% of procedures were performed in lower-volume centers, Mentias and colleagues wrote.
“In a large group of Medicare patients with obstructive hypertrophic cardiomyopathy, we demonstrate that both septal myectomy and alcohol septal ablation result in a significant reduction in rates of HF admission,” Mentias and colleagues wrote. “Although septal myectomy is associated with higher risk of short-term mortality and complications compared with alcohol septal ablation, it is associated with lower risk of mortality in the long term. Decision to pursue one type of septal reduction therapy over the other should be based on patient informed decision and heart team discussion.”
‘The opportunity for enhanced longevity’
In a related editorial, Martin S. Maron, MD, director of the Hypertrophic Cardiomyopathy Center and Research Institute at Lahey Medical Center in Burlington, Massachusetts, wrote that this study and a previous one “advance the principle that surgical septal myectomy can provide patients with the opportunity for enhanced longevity, including when performed in those of advanced age.”
Although it is unclear why septal myectomy seems to produce better long-term results, “residual outflow gradients present in some patients after alcohol septal ablation, in contrast to the more complete and permanent abolition of gradient with surgery, could over time be responsible for driving differences in long-term outcome,” Maron wrote.
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