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edited version myectomy vs. septal ablation

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  • edited version myectomy vs. septal ablation

    [edited version myectomy vs. septal ablation]

    Author: Bob Pensack,MD (---.tnt2.steamboat-springs.co.da.uu.net)

    Date: 10-17-02 17:59

    Dear Erica,

    Sorry, but I sent you a rather extensive e-mail this morning which was somehow lost. Unfortunately I did not save it so this will be a new attempt. You are indeed correct in your assumption that alcohol septal ablation of the septum is still a controversial issue. The larger centers such as the Mayo and Cleveland Clinic as well as Dr. Maron at the Minneapolis Heart Institute are in fact concerned that as of yet there is no long track record to see long term outcome results and possible complications down the road. They now have over a 40 year experience with septal myectomies, which have produced, for the most-part excellent results. Indeed this is why this surgery is still considered "the gold standard" for treatment obstructive HCM. The operative mortality rate in the hands of the best surgeons is close to 0%. I must emphasize however that only a few surgeons in the country have this vast experience with HCM. One of these is Dr. Gordon K. Danielson of the Mayo Clinic.

    On the other hand, Dr. William Spencer at the Medical University of South Carolina has the largest experience of alcohol septal ablation of any cardiologist in the United States. The overwhelming majority of his patients have done really well. He was trained by Dr. Hubert Seggewiss of Schweinfurt, Germany, who developed the technique. Dr. Spencer, as you probably already know, recently moved to SC from Baylor (the Texas Heart Institute) where he perfected his techniques.

    Your father's septum size of 3 to 3.5 sonometers is not a prognosticator of sudden death by itself. The true risk factors for sudden death, as outlined recently, at the HCM International Summit on Oct 4-6 are as follows: a) finding of 2 or more of the following features are felt to be associated with a higher incidence of sudden death 1) a family history of 2 or more premature (less than 40 years) sudden deaths 2) syncope within the previous year 3) the finding of nonsustained ventricular tachycardia on Holter 4) an abnormal exercise blood pressure response 5) severe left ventricular wall hypertrophy (greater than or equal to 3 sonometers) 6) a large left ventricular outflow tract obstructive gradient.

    It is generally felt that the finding of 2 or more above is associated with annual sudden death rates of 2-4%. It should be emphasized that these are not hard and fast rules and that each patient must be evaluated as an individual. It is felt that if the patient meets the above criteria it is a good idea for those patients to receive an AICD (Automatic Implantable Cardiac Defibrillator). Decisions for the above must be individualized based on age, intensity of the risk factors, etc.

    For what it is worth, if it was me or one of my loved ones, I would chose an alcohol septal ablation if the criteria for that is met by Dr. Spencer. If this did not produce the desired results, the gold standard of myectomy could still be done.

    I hope this answers all of your questions about your father. Please feel free to contact me in regards to all our HCM brothers and sisters.

    Sincerely,

    Bob Pensack, M.D.

    >From: Erica Stolzenberg

    >To: [email protected]

    >Subject: HCM and all you folks on this message board

    >Date: Wed, 16 Oct 2002 19:42:57 -0700 (PDT)

    >

    >

    >Dear Dr. Pensack:

    >

    >Thank you for posting on the HCMA board. I have a question for you about the septal alcohol ablation procedure. My father turns 58 on November 4th and he is scheduled to have his ablation on November 12th at the MUSC in SC. He was first diagnosed with IHSS in the mid to late 90's ... before that he was just told that he had high blood pressure and a murmur. He was officially diagnosed with the term HOCM a few weeks ago by his local cardiologist here in Cary, NC. He had his cath a few weeks ago and it was recommended that he either go for an ablation or myectomy. His septum size is 3.0 - 3.5. I asked his cardiologist if he was at high risk for sudden cardiac death and he said no (but I am keeping in mind that he is not an HCM specialist and could be uneducated about the true nature of HCM/HOCM. I also know my family history contains many deaths on my father’s side due to heart disease – heart attacks & strokes from my father’s age +) Dr. Spencer at the MUSC will evaluate my father on the morning of Nov.12th. He is scheduled to have the ablation that afternoon if Dr. Spencer believes he is a true match. Personally, I would love for my father to see an HCM specialist but he refuses to go to the Mayo Clinic or any other HCM center. I know it is because he is fearful of the myectomy. He feels that because these centers oppose the ablation … they will try and talk him out of it. I have been trying to convince him that their bias is only because the procedure is new and there isn't enough long-term data to back up their 'support.' I have been reading on the board that the procedure is not recommended for the younger population. My father obviously does not fall into this category but I just don’t know if he is making a wise decision. I welcome your thoughts on the procedure. I also welcome any additional thoughts or recommendations you might have to help me further educate my father! I love him and I do not want to misinform him. He listens to me because I am his first-born daughter who loves him dearly, and he listens to me because he knows I have a true understanding of health education. I attained my BS degree in Health Science with a dual concentration in Community and School health education (grades N-12.) Thank you in advance and I look forward to your reply!

    >

    >

    >

    >Best regards,

    >

    >Erica Stolzenberg

    >3 Trawick Court

    >Durham, NC 27713

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: edited version myectomy vs. septal ablation]

    Author: karen (---.ns.sympatico.ca)

    Date: 10-18-02 13:23

    I had the myectomy almost 15 years ago now in Canada. I have since had a daughter who is now 12 years old. I am only on one drug and I lead as normal a life as possible. I have trouble walking up hills and exercises, but at least I am able to watch my daughter grow. I would recommend this surgery to anyone who wants a few more years with their loved ones

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: edited version myectomy vs. septal ablation]

    Author: Erica Stolzenberg (---.biz.dsl.gtei.net)

    Date: 10-18-02 13:44

    Karen - thank you for sharing your personal story. I am happy to hear that the procedure worked for you! And what a joy to be able to watch your daughter grow into a young woman! Is your daughter symptomatic or asymptomatic? You didn't mention how she is doing! Have a great weekend. ~ Erica

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: edited version myectomy vs. septal ablation]

    Author: H. Seggewiss, A. Rigopoulos (---.dip.t-dialin.net)

    Date: 10-20-02 07:20

    Dear Dr. Bob Pensack,

    Your message about myectomy and alcohol septal ablation really provides a consice overview of both therapeutic modalities. We feel, however, that it would be a good idea to provide some more information on alcohol septal ablation.

    The technique was first performed by Prof. Ulrich Sigwart and the first results were published in 1995. We started treating patients in Heart Center, Bad Oeynhausen, Germany in 1996. After the first 25 patients that were treated in Bad Oeynhausen, we introduced the contrast echocardiographic monitoring as a substantial part of the procedure. Up to now, adding the experience in Schweinfurt, more than 600 patients have been treated by us using this improved technique. This technique involves the injection of contrast-echo medium in the target septal branch under echo monitoring before any alcohol is injected. Thus we are able to assess clearly the area of the septum that is going to be ablated. Furthermore, by using multiple echocardiographic views we are able to exclude the possibility of alcohol running to other - non-target - areas of the myocardium that we would under no circumstances want to ablate! In our experience, the angiographically assumed "target septal branch" would lead to alcohol misplacemet in about 9% of the cases, which underscores the importance of the contrast-echo monitoring.

    As for the echocardiographic and hemodynamic indications for septal ablation, patients should have sufficiently thick interventricular septum (at least 18 mm) and a substantial left ventricular outflow tract gradient at rest (>50 mmHg) and/or after provocation with Valsalva or after an extrasystole (>100mmHg). It is clear so far that this is a treatment indicated only for severely symptomatic patients. The follow up results have shown no increased mortality after the procedure, but whether long term prognosis is ameliorated still remains unresolved.

    Alcohol ablation programs have been initiated in several centers in Europe and USA in the last years. Unfortunately, in some centers alcohol ablation is performed by monitoring only the hemodynamic measurements, that is without the visual safety of echocardiographic guidance. Others use echo guidance but rely on the usually poor opacification quality of angiographic contrast dye. This method can sometimes aid the echocardiographic identification of the target area of the septum but, because of the poor contrast potential, it is doubtful if it can clearly depict any possible misplacements, i.e. in a papillary muscle or the left or right ventricular free wall.

    We hope the above information are helpful for the better understanding of the details associated with the procedure of alcohol septal ablation. Furthermore, for the sake of historical truth, we have to correct you on the fact that Dr. Spencer was never trained in Bad Oeynhausen or Schweinfurt. In fact, there has never been a collaboration of any kind between his and our team.

    In case further questions come up, please feel free to contact us.

    Yours sincerely

    Hubert Seggewiss

    Angelos Rigopoulos

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: edited version myectomy vs. septal ablation]

    Author: Erica (---.atlnga1.dsl-verizon.net)

    Date: 10-20-02 10:31

    Dear Dr. Seggewiss,

    Thank you for sharing such informative information. I greatly appreciate it.

    I was under the impression that Dr. Spencer studied under a doctor in the United Kingdom, at least that was what I read somewhere.

    I sent you a pesonal email and look forward to your reply!

    Kindest regards and warm wishes for this upcoming week to both you and Angelos Rigopoulos!

    ~ Erica Bsth Stolzenberg

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: edited version myectomy vs. septal ablation]

    Author: Lisa Salberg (---.dyn.optonline.net)

    Date: 10-21-02 09:14

    For anyone reading this post - the information you read above from Dr. Seggewiss at el is a great history lesson and very acurate information 'straight from the top'.

    Best to all

    Lisa

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: edited version myectomy vs. septal ablation]

    Author: Sarah B.-Board Moderator (---.client.attbi.com)

    Date: 10-23-02 00:16

    Hi

    For anyone not coversant in "doctorese" ---Dr. Seggewiss's posting says that his clinic uses a very effective contrast dye that shows the blood vessels to the best advantage. They use echos during the procedure to see the heart structure and between the echos and the dye, they have better results than procedures that don't.

    Also, the dye/medium that they use is not available in the US at all. There is another contrast dye that is in use. Still, the use of any dye is generally considered a more accurate way to do an ablation then relying on measuring the pressure gradient within the heart in order to tell if you have ablated the septum enough.

    I think I paraphrased that correctly. Please let me know (Lisa, Dr. Seggewiss) if I did not.

    Sarah

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: edited version myectomy vs. septal ablation]

    Author: Sarah B.-Board Moderator (---.client.attbi.com)

    Date: 10-23-02 17:14

    Addendum: the dye in use here in the states is not as good as the European dye.

    S

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: edited version myectomy vs. septal ablation]

    Author: Erica (---.atlnga1.dsl-verizon.net)

    Date: 10-23-02 17:44

    Sarah ,,, do you know anything about 'omnipaque'?

    Again ... sorry about earlier today! I think after my dad's procedure I will be taking a LONG vacation! Oh do I need a break! ~ Erica
    NOTE: This is a post from the previous forum message board.

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