interventional therapy in obstructive hypertrophic ... p_ vriesendorp cne 25 maart 2014... ·...
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Interventional therapy in obstructive hypertrophic
cardiomyopathy
P. A. Vriesendorp
CNE Utrecht, 25 maart 2014
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Disclosures
none
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Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy
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M. Maron et al. Circ 2006;114:2232-2239M. Maron et al. Circ 2006;114:2232-2239
Rest obstruction(119, 37%)
Provokable obstruction(106, 33%)
Nonobstructive(95, 30%)
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M. Maron et al. Circ 2006;114:2232-2239M. Maron et al. Circ 2006;114:2232-2239
Nonobstructive(95, 30%)
Rest obstruction(119, 37%)
Provokable obstruction(106, 33%)
70%
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Myectomy
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SP
LAD
Target septal perforator RAO
Alcohol septal ablationAlcohol septal ablation
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Balloon in the septal perforator artery
Alcohol septal ablationAlcohol septal ablation
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Alcohol septal ablationAlcohol septal ablation
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SP
Alcohol septal ablationAlcohol septal ablation
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Alcohol septal ablation or myectomy?Myectomy ASA
Procedural mortality <1% 1–2%
Post procedure gradient (rest) <10 mmHg <25 mmHg
Symptoms Improved Improved
Effective despite anatomic variation Yes Sometimes
Post procedure pacemaker 1–2% 5–10%
Late sudden-death risk Very low Uncertain
Available follow-up >40 years ~15 years
Modified from the American College of Cardiology and the European Society of Cardiology consensus
statement. Maron et al. Eur Heart J 2003
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Patiente A, º 1948
VG: HCM, COPD, DM
2006: vanuit Ikazia naar EMC owv 2nd Op.
2012: opnieuw verwezen bij ↑ klachten
Casus
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A: POB CCS klasse II-III, Dyspnoe NYHA III
LO: BMI 41(!), BD 110/70, syst souffle 3/6
Medicatie: metoprolol, verapamil, flixotide/ventolin
Casus
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TTE
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Angio
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Chirurgisch of percutaan?
DM, ernstig morbide obesitas, COPD
Geen CAD of (sub)valvulair-lijden
Euroscore-II: 1,43%
In HT wordt besloten tot percutane behandeling
Moet er invasief ingegrepen worden?
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Microspheres
Coils en covered stents: geen goede resultaten, daarom wordt gekozen voor:
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MicrospheresMicrospheres
Embozene ® microspheres: biocompatibel, niet absorbeerbaar
Gebruikt voor embolizatie van o.a. lever- en baarmoedertumoren
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Niet cardiotoxisch, infarct door
occlusie van septaaltak
Minder kans op collateralen??
Microspheres?
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Pre procedure
Vriesendorp et al. Neth Heart J 2013Vriesendorp et al. Neth Heart J 2013
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Vriesendorp et al. Neth Heart J 2013Vriesendorp et al. Neth Heart J 2013
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Post procedure
Vriesendorp et al. Neth Heart J 2013Vriesendorp et al. Neth Heart J 2013
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TTE na 3 dagen
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TTE na 3 maanden
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Recommendations Class Level
Septal reduction therapy should be performed only by experienced operators
I C
Surgical septal myectomy is the first consideration for the majority of eligible patients with HOCM
IIa B
Alcohol septal ablation may be beneficial if surgery is contraindicated or the risk is considered unacceptable
IIa B
Take home message 1
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Take home message 2
Korte termijn resultaten SME: veilig en effectief
Lange termijn onduidelijk – blijft de obstructie weg?