Outcome of Surgical Myectomy After Unsuccessful Alcohol Septal Ablation for the Treatment of Patients With Hypertrophic Obstructive Cardiomyopathy

Objectives: We sought to determine the outcome of myectomy after unsuccessful alcohol ablation. Background: Alcohol septal ablation results in symptomatic improvement and a reduction in dynamic obstruction in most hypertrophic obstructive cardiomyopathy patients. However, a few patients remain with severe symptoms and obstruction and need surgery. The outcome of these cases is not well known. Methods: The medical records of 375 patients who underwent alcohol ablation at our institution were reviewed. Twenty patients (5.3%, mean age 53 ± 18 years, 17 women) subsequently needed surgical myectomy. The New York Heart Association (NYHA) functional class, angina class, exercise duration, left ventricular outflow tract (LVOT) gradient, ejection fraction, and septal thickness were tabulated. The anatomy and distribution of the septal perforator arteries were examined. Results: After ablation, NYHA functional class (3 to 2.5; p < 0.05) and LVOT gradient (93 ± 23 mm Hg to 71 ± 26 mm Hg; p < 0.05) were slightly improved, without a change in exercise duration (171 ± 124 s to 168 ± 148 s; p > 0.5). Myectomy was performed at 19 ± 15 months after ablation. There was no operative mortality, but permanent pacing was needed in 2 patients after surgery, and 3 other cases needed pacing before, or as a complication of, alcohol ablation. A significant improvement was noted, with the NYHA functional class decreasing to 1, exercise duration increasing to 423 ± 171 s, and LVOT gradient decreasing to 6 ± 11 mm Hg (all p < 0.05 versus post-alcohol ablation). Conclusions: Myectomy can be successfully performed after failed alcohol ablation, but with a higher incidence of heart block than in cases where only surgery is performed. Otherwise, alcohol ablation does not appear to adversely affect surgical outcome.