![]() ![]() 3 Hypertrophic cardiomyopathy is a young disease and, although the first anatomic description of diffuse muscular hypertrophy of the left ventricular outflow tract was published in 1907, 4 the first contemporary description was reported in the 1950s 5 and, as our understanding of this disease or group of disease entities has grown, it remains a topic of interest and fascination. Braunwald stated that “in looking back on my career, the work on hypertrophic cardiomyopathy was clearly the most exciting that I have ever done”. Based upon these results, the number of ASA in this particular population can be expected to increase in Spain. ![]() Interestingly, 42% of the patients had received a pacemaker prior to the ASA procedure, which mitigates against the worrisome-and most common-complication of complete heart block, which can occur hours to days after ASA. ![]() They are primarily older women, who would have an increased risk of septal myectomy. The patient population in the study herein discussed appears to be an ideal cohort of patients to undergo ASA. Other changes in technique, such as using small, flexible, screw-in temporary pacemaker wires to avoid myocardial perforation, all come with experience. The selection of smaller branches of septal perforator arteries that directly target the region of systolic anterior motion with septal contact using echographic contrast injections allows for smaller volumes of alcohol while maintaining the optimal hemodynamic results. The mean of 3.7 mL of alcohol used in the study herein discussed is larger than the 1.5 to 2.0 mL used by more experienced centers and may account for the need for transplant and implantable cardioverter-defibrillators (ICD) in the patient cohort. There is a balance between a higher volume of alcohol used in the procedure producing better hemodynamic results and the possible long-term detrimental consequences of adverse myocardial remodeling and ventricular arrhythmias. 2 Thus, it would be expected that the long-term results of ASA in Spain will become even better as centers gain greater experience. ![]() We and others have shown that the success and complications rate of ASA significantly improve after a procedural volume of > 50 patients. The authors clearly state in their discussion that the results of either septal myectomy or ASA depend on operator experience, as well as an understanding of the disease itself. In addition, it would have been interesting to know whether the surgical myectomy population differed from those undergoing ASA or whether the decision was made on the basis of institutional expertise and facilities. It would have been of interest to know whether the use of septal reduction therapy increased over time. The numbers of patients in this reported experience from 5 centers is small, as are the numbers undergoing surgical myectomy. 1 Although the series reflects an earlier experience with a technique that continues to evolve over time, the encouraging long-term outcomes bode well for the next generation of patients who will undergo ASA after what we would hope is an adequate trial of medical therapy. The article published in Revista Española de Cardiología describing the 10-year follow-up after alcohol septal ablation (ASA) in patients with hypertrophic obstructive cardiomyopathy (HOCM) is a welcome addition to the literature. ![]()
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