The cause of mortality was known in 371 of the 445 deaths (83.4%).  C, Ingles Survival after repeat myectomy was similar to that of an age- and gender-matched Minnesota population (P = .46; Figure 3). Hsich Low operative mortality achieved with surgical septal myectomy: role of dedicated hypertrophic cardiomyopathy centers in the management of dynamic subaortic obstruction. This study suggests that clinicians should focus on early identification of disease in both women and men and promptly refer patients who do not respond to medical treatment for surgical evaluation. We reviewed available clinical and echocardiographic data from all eligible patients and stratified the study cohort by sex. View Large Download. Warnes Wang  MD, Devlin Provoked gradients were determined by provocative maneuvers (ie, Valsalva maneuver, amyl nitrite inhalation, and exercise). Robbins RC, Stinson EB. Sex and gender differences in myocarditis and dilated cardiomyopathy. The 5-year overall survival rate [96.8% (86.3-99.3) after myectomy and 93.5% (85.9-97.1) after ablation; P = 0.103] and cumulative incidence of sudden cardiac death [0% and 1.9% (0.5-7.5), respectively P = 0.797] did not differ between the groups. Statistical significance was defined as P ≤ .05, and analyses were performed using SAS version 9.4 (SAS Institute Inc) and R version 3.2.3 (R Foundation for Statistical Computing) from December 2017 to December 2018. Bos Ommen SR, Maron BJ, Olivotto I.  WG, Choi Concept and design: Meghji, Nguyen, Fatima, Nishimura, Ommen, Dearani.  et al.  LT The Cox model was also used to analyze postoperative length of stay, with in-hospital deaths censored and tied responses handled exactly in the model. Patient demographics are shown by sex in Table 1.  LG, Lai  GL, Turner The rate of new pacemakers required for high-degree heart block was 9.7%.  TA, Riordan The explanation for the different results is not clear. Survival after alcohol septal ablation for obstructive hypertrophic cardiomyopathy. There were no sex differences in the other comorbidities, nor were there differences in the use of any preoperative medical therapy between women and men. This is a retrospective study from a single tertiary center.  BJ, Dearani Get free access to newly published articles. B, Adjusted (Cox-Kalbfleisch-Prentice) estimates of survival for women and men in a combined sample of 2328 patients (92.9% of the entire cohort) who had complete information with respect to the baseline adjustment factors. These estimates were significantly worse than those of age-matched women in the general US population (238 observed vs 152.3 expected deaths; P < .001), whereas observed and population-based survival estimates for men varied considerably over time but did not have significantly different means (207 observed vs 184.7 expected deaths; P = .10) (Figure 1A).  CJ, Durham Maron  P, Barst This retrospective, single-center study included the clinical data of adult patients who underwent septal myectomy from January 1961 through April 2016. Factors associated with overall mortality included older age at surgery, greater body mass index, higher NYHA class, diabetes mellitus, and surgery performed earlier in the study period.  SR. For continuous variables, hazard ratios were calculated comparing the 75th percentile with the 25th percentile. Orme Geske Habib 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. Clinical and echocardiographic determinants of long-term survival after surgical myectomy in obstructive hypertrophic cardiomyopathy. Ejection fraction, left ventricular (LV) cavity size, LV mass, and wall thickness were determined as previously described.18 Mitral regurgitation was graded as none to trivial (0), mild (1), moderate (2), moderately severe (3), or severe (4) after analyzing jet area and width, and spectral Doppler intensity, as well as regurgitation quantitation with the continuity and/or proximal isovelocity surface area method, as appropriate.19 Mitral regurgitation could not be quantitated in all patients due to jet eccentricity and LVOT turbulence merging with the regurgitant jet flow convergence. ARF indicates acute renal failure; PPM, permanent pacemaker. Sex differences in mortality after coronary artery bypass graft surgery. According to a recent review, SM offers better LVOT gradient resolution than alcohol septal ablation (ASA). However, after adjustment for important baseline prognostic factors, there was no survival difference after septal myectomy by sex.  et al. Procedures include septal myectomy and septal ablation. eFigure. Recently published studies of long-term follow-up of patients after alcohol septal ablation in Europe, where surgical myectomy is rarely performed, confirm long-term safety and effectiveness with survival free of cardiac events exceeding 96% at 15 years.  et al. Circulation 2012;126:2374-80. Raphael For example, left atrial diameter was independently associated with late mortality in the study from Toronto, Ontario, Canada, but in a recent investigation from the study clinic, left atrial size, as measured by left atrial volume index, was not associated with late death.24 Another difference in the studies was the finding in the patients that diabetes is an important factor associated with overall mortality. Furthermore, a global test of all interaction terms between sex and the other covariates suggested no important sex-specific effects on mortality risk (χ224 = 27.2; P = .29). Women had more severe obstructive physiology as reflected in greater median (IQR) resting LVOT gradients (women, 67 [36-97] mm Hg; men, 50 [23-81] mm Hg; P < .001) and median (IQR) provoked LVOT gradients (women, 81 [64-208] mm Hg; men, 74 [55-100] mm Hg; P < .001) among those subsets of patients with available measurements.  MV, Hernandez Maron  RJ, Newby  RJ. Fairweather The analysis is limited by inherent selection bias.  I, Alcohol septal ablation is a less invasive treatment. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. Length of hospital stay was lower in the ASA group (3 days vs 6 days for both age groups, p <0.001) as well as median hospital costs (≤65 years old: $15,474 vs $31.531; and >65 years old: $16,672 vs $36,042, p <0.001). Data analysis occurred from December 2017 to December 2018.  D, Cooper  EM, Strait  MJ. 2005;14(11):60. Women also had more severe obstructive physiology and diastolic dysfunction in association with smaller LV mass index on echocardiography. Independent variables that violated proportional hazards (atrial fibrillation and left ventricular ejection fraction) were entered into the model as stratification variables rather than as covariates as a way to adjust for outcome without the need to assume proportional hazards. 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.  et al.  J, Maron  AH, Benjamin Patients with preoperative AF had marginally reduced survival (HR, 1.36; 95% CI, 0.97-1.91; P = .070) following septal myectomy after adjustment for comorbidities. Survival.  HV, Gersh Acquisition, analysis, or interpretation of data: Meghji, Nguyen, Fatima, Geske, Lahr, Schaff. In this retrospective study, septal myectomy seems to reduce mortality risk in severely symptomatic patients with obstructive HCM. Septal myectomy. Plot of Log Relative Hazard of Mortality for All Modeled Variables Included in the Multivariable Analysis, Table 1.  J, Zou  G,  EJ,  JL, Tajik Long-term results of left ventricular myotomy and myectomy for obstructive hypertrophic cardiomyopathy. Left ventricular (LV) outflow tract obstruction in HCM increases the likelihood of heart failure and cardiovascular death. Published by Elsevier Inc. All rights reserved. Drafting of the manuscript: Meghji, Nguyen, Fatima, Schaff.  RA, Seggewiss The perioperative mortality rate for isolated septal myectomy in most centers is <1%.  Y, Wang There was no significant difference in reduction of anteroseptal wall thickness, but adjusted difference in reduction of posterior wall thickness was greater in women than men (−0.9 [95% CI, −1.2 to −0.6; −0.5 [95% CI, −0.7 to −0.2]; P = .006). Temporal trend in baseline characteristics by sex.  Jr, Blauwet In this large cohort of surgical patients with obstructive HCM, women were older and more symptomatic at clinical presentation compared with men. Editor’s choice-sex differences in young patients with acute myocardial infarction: a VIRGO study analysis.  et al.  KJ. Results  View Large Download. Survival Differences in Women and Men After Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy. In more recent years, the median age of both women and men has increased, and preoperative resting gradient has decreased (eTable in the Supplement). Twelve-year follow-up of American women’s awareness of cardiovascular disease risk and barriers to heart health. After operation, 1-year, 10-year, and 20-year survival estimates were 98%, 85%, and 52%, respectively. Data analysis occurred from December 2017 to December 2018. Cardiac-related deaths occurred in 224 (56%), with hypertrophic cardiomyopathy the primary cause of death in 64. Adverse In-Hospital Event Rates After Septal Myectomy and Alcohol Septal Ablation by Tertiles of Hospital Volume. To analyze preoperative characteristics and overall survival of women and men undergoing septal myectomy for obstructive HCM. A study that did a long term follow up found that life expectancy of HCM patients who underwent septal myectomy approached that of the general population (survival rates for one, five, and 10 years were 98 percent, 96 percent, and 83 percent, respectively).  KC, ... Surgical septal myectomy uniformly decreases left ventricular outflow tract obstruction and improves symptoms, and in experienced centers has a surgical mortality of less than 1%, as well as 85% success rate.  RA, In hypertrophic cardiomyopathy, the walls of the ventricles and septum may thicken abnormally. Generally, a transaortic septal myectomy is performed to treat HOCM, with good outcomes reported in the literature. Mosca All Rights Reserved. Sorajja P, Ommen SR, Holmes DR Jr, et al. Including two operative deaths (procedural mortality, 0.8%), 1-, 5-, and 10-year overall survival after myectomy was 98%, 96%, and 83%, respectively, and did not differ from that of the general U.S. population matched for age and gender (p = 0.2) nor from patients with nonobstructive HCM (p = 0.8). AV, aortic valve; MV, mitral valve; TV, tricuspid valve; CABG, coronary artery bypass graft. Myectomy and nonoperated ob- In that analysis, women had poorer survival than men, and septal reduction was performed in only 32%.  MS, At the time of surgery, women were older, with median (IQR) age of 59.5 (46.6-68.2) years vs 52.9 (42.9-62.7) years in men (. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Nishimura eTable. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC).  RP,  A, Schwann  L, Mochari-Greenberger 3 However, alcohol septal … In this study of clinical data collected from 1961 to 2016, women were significantly older at the time of surgery, but adjusted statistics of survival were similar between women and men. Hypertrophic obstructive cardiomyopathy: surgical myectomy and septal ablation. Septal myectomy is associated with a low perioperative mortality and a high late survival rate.  et al. Agarwal S, Tuzcu EM, Desai MY, et al. Supervision: Schaff, Geske, Ommen, Dearani. Curve estimates trend over time stratified by sex using a locally weighted scatterplot smooth (loess).  SJ,  A. Factors Associated With Mortality After Septal Myectomy. Conflict of Interest Disclosures: None reported. A total of 2506 adults were included; 1379 patients (55.0%) were men. A muscular wall called the septum separates the left and right ventricles, the 2 lower chambers of the heart. Shapiro Semsarian Table 2 shows observed changes in echocardiographic parameters, as well as expected mean changes for women and men with baseline measurement and other covariates, adjusted to their median levels. These results differ from a report by Geske et al,5 who studied more than 3600 patients with HCM, most of whom had no LVOT obstruction. Determinants of reverse remodeling of the left atrium after transaortic myectomy. Are there any survival differences in women and men undergoing septal myectomy for hypertrophic cardiomyopathy? The distribution of women vs men undergoing myectomy has remained fairly stable through time (for example, 1960-1979: 22 of 1127 women [2.0%]; 27 of 1379 men [2.0%]; 2010-2016, 514 of 1127 women [45.6%]; 615 of 1379 men [44.6%]; P = .81 across all 5 decades; Table 1), and additional demographic data stratified by decade are shown in the eTable and the eFigure in the Supplement.  L, Linfante  I, Maron However, after adjustment for important baseline prognostic factors, there was no survival difference after septal myectomy by sex.  E, Clayton Early and late results from the present study, however, show that regardless of potential referral bias, surgical myectomy is an excellent treatment option for women with obstructive HCM. The purpose of this study is to compare overall survival between surgical septal myectomy and alcohol septal ablation. A septal myectomy is an open-heart procedure in which the surgeon removes part of the thickened, overgrown septum between the ventricles. Relationship between sex, shape, and substrate in hypertrophic cardiomyopathy. Are there any survival differences in women and men undergoing septal myectomy for hypertrophic cardiomyopathy? In all these regression models, continuous covariates were fitted using restricted cubic splines with 4 knots to relax linearity assumptions and to allow nonlinear effects. Septal hypertrophy, measured as median (IQR) absolute anteroseptal thickness (women, 19 [17-23] mm; men, 20 [18-23] mm) and median (IQR) posterior wall thicknesses (women, 13 [11-15] mm; men, 14 [12-15] mm), was less pronounced in women (both P < .001). Overall survival after septal myectomy was worse in women than men.  H, Schaff To analyze preoperative characteristics and overall survival of women and men undergoing septal myectomy for obstructive HCM. 4 Septal myectomy has also been reported to lead to good results in cases of Noonan syndrome accompanied by HOCM. Right ventricular systolic pressure was estimated in a standard procedure as per American Society of Echocardiography guidelines.20 Information from the most recent Doppler echocardiograms performed before septal myectomy were compared with those obtained postoperatively prior to hospital dismissal. Compared to nonoperated obstructive HCM patients, myectomy patients experienced superior survival free from all-cause mortality (98%, 96%, and 83% vs. 90%, 79%, and 61%, respectively; p < 0.001), HCM-related mortality (99%, 98%, and 95% vs. 94%, 89%, and 73%, respectively; p < 0.001), and sudden cardiac death (100%, 99%, and 99% vs. 97%, 93%, and 89%, respectively; p = 0.003).  A, Kühl Lo ng-term effects of surgical Septal Myectomy on survival in patients with obstructive Hypertrophic Cardiomyopath y. ACC Current J Review. Hypertrophic cardiomyopathy (HCM) is characterized by the presence of an increased thickness of the left ventricular (LV) wall that is not solely explained by abnormal loading conditions, including hypertension and/or valvular diseases.1,2 Two-thirds of patients with HCM have evidence of LV outflow tract obstruction, which is usually based on basal septal hypertrophy in combination with elongated mitral leaflet(s), causing systolic anterior motion of the mitral valve.1–3 In patients who remain highly sympto… There has been accumulating interest in sex-specific differences and outcomes in a variety of cardiovascular diseases, including HCM, and most studies have shown that women experience worse outcomes than men.5-16 Women with HCM are diagnosed at an older age, tend to be more symptomatic at presentation, have more obstructive physiology, and have reduced survival compared with men.5,17 However, the delay in presentation may not necessarily result in worse survival, and survival differences after myectomy to provide durable relief of LVOT obstruction are less well understood. Meaning  We use cookies to help provide and enhance our service and tailor content and ads. Long-Term Effects of Surgical Septal Myectomy on Survival in Patients With Obstructive Hypertrophic Cardiomyopathy. Thirty-four patients who did not consent for research were excluded from this analysis.  P.  Sex differences in the prognosis of congestive heart failure: results from the Cardiac Insufficiency Bisoprolol Study (CIBIS II). Each myectomy patient was matched to the U.S. white population by age, gender, and year of study entry. Interestingly, women were less likely to undergo concomitant coronary artery bypass grafting (women, 80 [7.2%]; men, 140 [10.3%]; P = .008), but the percentage who underwent concomitant valve operations was not significantly different (women, 451 [40.7%]; men, 509 [37.4%]; P = .10). Survival curves are adjusted to the median levels of continuous covariates and modal categories of categorical covariates from the combined sample; the resulting difference is nonsignificant. Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. J Thorac Cardiovasc Surg.  MS.  A discussion of contemporary nomenclature, diagnosis, imaging, and management of patients with hypertrophic cardiomyopathy.  LA. A, Unadjusted sex-specific estimates of survival compared with corresponding age-matched, sex-matched US population rates.  A, Schaff New-onset atrial fibrillation: sex differences in presentation, treatment, and outcome. Information from transthoracic echocardiographic examination was available in patients from November 1974. However, there were no differences between the 2 sexes in early postoperative outcomes, including mortality and relief of LVOT obstruction.  MA, These results also contrast with the investigation by Olivotto et al,17 who observed worse chances of survival in women with HCM; however, in their study, only 10% of patients had advanced (NYHA class III or IV) symptoms, and less than 30% had important LVOT obstruction. Importantly, women were older and more symptomatic than men at the time of surgery.  JT, Rates in men and women are about equal. Women with hypertrophic cardiomyopathy have worse survival. 1, 2 Septal myectomy (SM) is still considered as the first line septal reduction method in patients who are deemed appropriate surgical candidates and when surgical expertise is available. Customize your JAMA Network experience by selecting one or more topics from the list below.  BJ, Bonow  et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; 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; Society of Thoracic Surgeons. The heart, Turner M, et al in presentation, treatment, and management of dynamic subaortic obstruction outcome! Gradient resolution than alcohol septal ablation Cardiology, https: // and there were no differences the. Involves reducing thickened heart muscle walls, while ablation involves reducing thickened heart muscle.., 2003-2011 a was available in patients with hypertrophic cardiomyopathy centers in the clinical data and echocardiography measurements … myectomy. 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Cardiovascular disease risk and barriers to heart health option for severely symptomatic patients with obstructive HCM study cohort sex.

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