- Email: [email protected]
Reply to Letter From Wallace et al.—Septal Perforator Size May Play a Key Role in Alcohol Septal Ablation Success
Accepted Manuscript Angiographic and Echocardiographic Correlates of Suitable Septal Perforators for Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy – Reply to Wallace et al. Septal perforator size may play a key role in alcohol septal ablation success William Chan, MB, BS, PhD Christopher B. Overgaard, MD, MSc, FRCPC
PII:
S0828-282X(14)00321-3
DOI:
10.1016/j.cjca.2014.05.001
Reference:
CJCA 1211
To appear in:
Canadian Journal of Cardiology
Received Date: 1 May 2014 Accepted Date: 2 May 2014
Please cite this article as: Chan W, Overgaard CB, Angiographic and Echocardiographic Correlates of Suitable Septal Perforators for Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy – Reply to Wallace et al. Septal perforator size may play a key role in alcohol septal ablation success, Canadian Journal of Cardiology (2014), doi: 10.1016/j.cjca.2014.05.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Angiographic and Echocardiographic Correlates of Suitable Septal Perforators for Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy – Reply to Wallace
RI PT
et al. Septal perforator size may play a key role in alcohol septal ablation success
William Chan MB, BS, PhD, Christopher B Overgaard MD, MSc, FRCPC
SC
Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health
Corresponding author/address:
M AN U
Network, Toronto, Ontario, Canada
Christopher B. Overgaard, MD, MSc., FRCPC
6 Eaton North Room 232, Toronto General Hospital
TE D
University Health Network 200 Elizabeth Street, Toronto ON M5G 2C4 Phone: (416) 340-4800 x 6265
EP
Fax: (416) 340-3390
AC C
[email protected]
ACCEPTED MANUSCRIPT
We thank Wallace and colleagues for highlighting their research which demonstrated a significant association between the ostial first septal perforator (FSP) diameter measured by quantitative coronary angiography (QCA) with greater incidences of extra septal perfusion
RI PT
(ESP).1 Specifically, 12 out of 47 patients in their alcohol septal ablation (ASA) cohort exhibited ESP with larger ostial diameters compared to those with no ESP (1.69mm vs. 1.23mm, p=0.04). Importantly, their work appear consistent with our own observations that patients in whom ASA was aborted had larger target septal diameters compared to those who underwent successful
M AN U
SC
ASA, 2.1mm vs. 1.8mm, p=0.04.2
The main objective of our research was to evaluate whether there were additional angiographic and/or echocardiographic markers that might identify patients who were deemed to be anatomically suitable for ASA. We observed a significant correlation between ostial left main to target septal distance measured on QCA and the distance from basal septum to the septal area
TE D
corresponding to where the systolic anterior motion of mitral valve (SAM) contacted the septum (SAM-septal contact point) on echocardiography (p<0.001). The clinical implication of this finding is that this simple distance measure may be useful in pre-procedural selection of
EP
appropriate septal perforator(s) for ASA. It also underscores the anatomical location of the
AC C
target septal vessel with the perfusion of the septum.
We were intrigued by the separate finding of a larger target septal ostial diameter found in our ‘No ASA’ group. Interestingly, 10 out of these 11 patients (91%) also exhibited ESP. While we acknowledge this statistical difference, we had reservations about its clinical significance given the small sample size of our ‘No ASA’ cohort. Additionally, patients referred for ASA were likely already pre-selected by screening angiography so that the exact denominator of patients needing septal reduction is possibly much larger. It would have been useful to be able to systematically assess by QCA and echocardiography the target or FSP in all patients referred
ACCEPTED MANUSCRIPT
for ASA including those with no obviously suitable septal perforators, which might have improved detection of predictors of ASA failure. However, our registry unfortunately does not
RI PT
capture these patients.
In light of the current observational data from 2 independent groups demonstrating an
association between larger ostial diameter of the target septal (FSP) and ESP, we agree with
SC
Wallace et al that this warrants further study. Indeed, if confirmed by larger studies, this easily assessable angiographic variable could be utilized as an additional angiographic characteristic
M AN U
in the selection/exclusion of patients for ASA. We therefore warmly welcome future collaboration with Wallace and colleagues to elucidate further angiographic variables that help refine patient
AC C
EP
TE D
selection for ASA.
ACCEPTED MANUSCRIPT
Funding Dr. Chan is supported by the National Health and Medical Research Council of Australia Early
RI PT
Career Fellowship (Neil Hamilton Fairley – Clinical Overseas Fellowship) (APP1052960).
Disclosures
AC C
EP
TE D
M AN U
SC
None.
ACCEPTED MANUSCRIPT
References 1.
Wallace EL, Thompson JJ, Faulkner MW, Gurley JC, Smith MD. Septal perforator anatomy and variability of perfusion bed by myocardial contrast
RI PT
echocardiography: A study of hypertrophic cardiomyopathy patients undergoing alcohol septal ablation. J Interv Cardiol. 2013;26:604-612
Chan W, Williams L, Kotowycz MA, Woo A, Rakowski H, Schwartz L,Overgaard
CB, Angiographic
SC
2.
and Echocardiographic Correlates of Suitable Septal Perforators for
M AN U
Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy, Canadian Journal
AC C
EP
TE D
of Cardiology (2014), doi: 10.1016/j.cjca.2014.04.008
PII:
S0828-282X(14)00321-3
DOI:
10.1016/j.cjca.2014.05.001
Reference:
CJCA 1211
To appear in:
Canadian Journal of Cardiology
Received Date: 1 May 2014 Accepted Date: 2 May 2014
Please cite this article as: Chan W, Overgaard CB, Angiographic and Echocardiographic Correlates of Suitable Septal Perforators for Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy – Reply to Wallace et al. Septal perforator size may play a key role in alcohol septal ablation success, Canadian Journal of Cardiology (2014), doi: 10.1016/j.cjca.2014.05.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Angiographic and Echocardiographic Correlates of Suitable Septal Perforators for Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy – Reply to Wallace
RI PT
et al. Septal perforator size may play a key role in alcohol septal ablation success
William Chan MB, BS, PhD, Christopher B Overgaard MD, MSc, FRCPC
SC
Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health
Corresponding author/address:
M AN U
Network, Toronto, Ontario, Canada
Christopher B. Overgaard, MD, MSc., FRCPC
6 Eaton North Room 232, Toronto General Hospital
TE D
University Health Network 200 Elizabeth Street, Toronto ON M5G 2C4 Phone: (416) 340-4800 x 6265
EP
Fax: (416) 340-3390
AC C
[email protected]
ACCEPTED MANUSCRIPT
We thank Wallace and colleagues for highlighting their research which demonstrated a significant association between the ostial first septal perforator (FSP) diameter measured by quantitative coronary angiography (QCA) with greater incidences of extra septal perfusion
RI PT
(ESP).1 Specifically, 12 out of 47 patients in their alcohol septal ablation (ASA) cohort exhibited ESP with larger ostial diameters compared to those with no ESP (1.69mm vs. 1.23mm, p=0.04). Importantly, their work appear consistent with our own observations that patients in whom ASA was aborted had larger target septal diameters compared to those who underwent successful
M AN U
SC
ASA, 2.1mm vs. 1.8mm, p=0.04.2
The main objective of our research was to evaluate whether there were additional angiographic and/or echocardiographic markers that might identify patients who were deemed to be anatomically suitable for ASA. We observed a significant correlation between ostial left main to target septal distance measured on QCA and the distance from basal septum to the septal area
TE D
corresponding to where the systolic anterior motion of mitral valve (SAM) contacted the septum (SAM-septal contact point) on echocardiography (p<0.001). The clinical implication of this finding is that this simple distance measure may be useful in pre-procedural selection of
EP
appropriate septal perforator(s) for ASA. It also underscores the anatomical location of the
AC C
target septal vessel with the perfusion of the septum.
We were intrigued by the separate finding of a larger target septal ostial diameter found in our ‘No ASA’ group. Interestingly, 10 out of these 11 patients (91%) also exhibited ESP. While we acknowledge this statistical difference, we had reservations about its clinical significance given the small sample size of our ‘No ASA’ cohort. Additionally, patients referred for ASA were likely already pre-selected by screening angiography so that the exact denominator of patients needing septal reduction is possibly much larger. It would have been useful to be able to systematically assess by QCA and echocardiography the target or FSP in all patients referred
ACCEPTED MANUSCRIPT
for ASA including those with no obviously suitable septal perforators, which might have improved detection of predictors of ASA failure. However, our registry unfortunately does not
RI PT
capture these patients.
In light of the current observational data from 2 independent groups demonstrating an
association between larger ostial diameter of the target septal (FSP) and ESP, we agree with
SC
Wallace et al that this warrants further study. Indeed, if confirmed by larger studies, this easily assessable angiographic variable could be utilized as an additional angiographic characteristic
M AN U
in the selection/exclusion of patients for ASA. We therefore warmly welcome future collaboration with Wallace and colleagues to elucidate further angiographic variables that help refine patient
AC C
EP
TE D
selection for ASA.
ACCEPTED MANUSCRIPT
Funding Dr. Chan is supported by the National Health and Medical Research Council of Australia Early
RI PT
Career Fellowship (Neil Hamilton Fairley – Clinical Overseas Fellowship) (APP1052960).
Disclosures
AC C
EP
TE D
M AN U
SC
None.
ACCEPTED MANUSCRIPT
References 1.
Wallace EL, Thompson JJ, Faulkner MW, Gurley JC, Smith MD. Septal perforator anatomy and variability of perfusion bed by myocardial contrast
RI PT
echocardiography: A study of hypertrophic cardiomyopathy patients undergoing alcohol septal ablation. J Interv Cardiol. 2013;26:604-612
Chan W, Williams L, Kotowycz MA, Woo A, Rakowski H, Schwartz L,Overgaard
CB, Angiographic
SC
2.
and Echocardiographic Correlates of Suitable Septal Perforators for
M AN U
Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy, Canadian Journal
AC C
EP
TE D
of Cardiology (2014), doi: 10.1016/j.cjca.2014.04.008