Author + information
- Neeraj Parakh, MD, DM⁎ ( and )
- Balram Bhargava, MD, DM, FRCP, FACC
- ↵⁎Suite no-124, 1st floor, Academic block, G.B. Pant Hospital, New Delhi-110002, India
The recent article by Kwon et al. (1) in JACC: Cardiovascular Interventions provokes mixed feelings. It is encouraging to note that 55 high-risk patients with hypertrophic obstructive cardiomyopathy, who were surgical rejects underwent alcohol septal ablation (ASA) without any periprocedural mortality. However, the rate of development of complete heart block (CHB) requiring permanent pacemaker implantation was alarmingly high. If we exclude 11 patients who had permanent pacemaker implantation at baseline, then the rate of new permanent pacemaker implantation is actually 32% (14 of 44), which is highly unacceptable today. We believe that there are 2 possible explanations for this high rate of development of CHB. First, all the surgical rejects were subjected to alcohol septal ablation, irrespective of the anatomy of the first septal unit (2). Alcohol septal ablation remains successful only when anatomy of the first septal unit is suitable. Performing ASA in all patients irrespective of the anatomy of the first septal unit is bound to have higher complication rates. Second, the amount of alcohol used during the procedure clearly determines the complication of CHB (3). There was no mention of the amount of alcohol used for ASA, so it may be an important explanation for the very high complication rate. Because these cases were done between 1997 and 2000, it is very possible that the amount of alcohol used was not judicious. The relationship between amount of alcohol used and development of CHB has been well established only recently.
Further, this study was done at a center where surgical expertise and experience for myectomy is one of the best available in the world and only surgical rejects were treated with ASA (4). This means very serious patients indeed underwent ASA. This is in contrast to the real-world setting wherein surgical expertise and experience is not easily available. Only ASA rejects or poor anatomical candidates undergo myectomy. It is because of these differing practice patterns that operators achieve differing levels of expertise in this procedure (5,6).
In today's world, surgical expertise remains limited to a few centers, practicing patterns remain diagonally opposite (primarily ASA vs. primarily myectomy), and patient preference remains inclined for a lesser invasive procedure. It is clear that the joys of alcohol are brief; the results are lasting indeed! This procedure has been shown to be highly effective in surgical rejects as well.
- American College of Cardiology Foundation
- Kwon D.H.,
- Kapadia S.R.,
- Tuzcu E.M.,
- et al.
- Maron B.J.
- Fifer M.A.
- Sigwart U.