Horst Kuhn

Role of Transcoronary Ablation of Septal Hypertrophy in Patients With Hypertrophic Cardiomyopathy, New York Heart Association Functional Class III or IV, and Outflow Obstruction Only Under Provocable Conditions

Background—Transcoronary ablation of septal hypertrophy (TASH) for hypertrophic cardiomyopathy seems to be an effective alternative to surgical myectomy. It remains a point of debate whether an outflow obstruction at rest is a necessary criterion for interventional therapy. Methods and Results—TASH was compared in 45 consecutive patients with no resting gradient and a provocable gradient of ≥30 mm Hg (group I) and in 84 consecutive patients with a resting gradient of ≥30 mm Hg (80±33 mm Hg) (group II). At baseline, all patients were in NYHA functional class (FC) III or IV, unresponsive to medical treatment. Patients in group I were older (63±12 versus 55±17 years, P =0.005) and had a lower postextrasystolic gradient (110±44 versus 171±40 mm Hg, P <0.001). The groups were similar with respect to NYHA FC (3.1±0.3 versus 3.1±0.3), basal septal thickness (22±4 versus 23±3 mm), maximal oxygen consumption (13.1±4.6 versus 14.5±5.0 mL/kg per minute), and pulmonary artery mean pressure at workload (42±9 versus 42±10 mm Hg) (P >0.05). Median follow-up was 7 months after TASH. The 2 groups showed a significant and similar improvement in provocable obstruction (to 24±24 and 56±51 mm Hg, respectively), basal septal thickness (to 12±3 and 12±4 mm, respectively), NYHA FC (to 1.7±0.6 and 1.5±0.6, respectively), maximal oxygen consumption (to 16.0±5.3 and 16.6±6.0 mL/kg per minute, respectively), and pulmonary artery mean pressure at workload (to 36±9 and 34±9 mm Hg, respectively) (P >0.05). Conclusions—TASH seems to have beneficial clinical and hemodynamic effects in patients with either provocable or resting outflow obstruction.

Left ventricular outflow tract obstruction in patients with hypertrophic cardiomyopathy : increase in gradient after exercise

To define alterations in the magnitude of the left ventricular outflow tract gradient during supine exercise, 10 patients with hypertrophic obstructive cardiomyopathy were studied under basal conditions and during exercise and recovery with simultaneous invasive hemodynamic measurements, particularly of the peak to peak systolic pressure gradient across the left ventricular outflow tract. Basal outflow pressure gradient ranged from 0 to 89 mm Hg (average 37.4 +/- 9.6). No increase was observed during 5 min of exercise (average 29.6 +/- 10 mm Hg, range 0 to 91; p = NS), even though arterial blood pressure, heart rate and cardiac index increased significantly in association with a decrease in peripheral vascular resistance. However, a rapid and highly significant increase in left ventricular outflow gradient occurred after exercise was completed (average 83.5 +/- 11.4 mm Hg, range 10 to 130; p less than 0.001), while arterial blood pressure, heart rate and cardiac index closely approached basal levels and total peripheral vascular resistance increased. In contrast to previous assumptions regarding the behavior of the outflow gradient in hypertrophic cardiomyopathy, obstruction to left ventricular outflow increases after rather than during supine exercise. Rapid changes in preload during recovery represent the most likely explanation for the postexercise development of outflow obstruction. New considerations regarding the mechanisms of sudden cardiac death and the therapeutic approach in patients with hypertrophic cardiomyopathy may result from this pathophysiologic observation.

Transcoronary Ablation of Septal Hypertrophy Does Not Alter ICD Intervention Rates in High Risk Patients with Hypertrophic Obstructive Cardiomyopathy

Introduction: Transcoronary ablation of septal hypertrophy (TASH) is safe and effectively reduces the intraventricular gradient in patients with hypertrophic obstructive cardiomyopathy (HOCM). To analyze the potential of anti‐ and proarrhythmic effects of TASH, we studied the discharge rates of implanted cardioverter defibrillators (ICD) in patients with HOCM who are at a high risk for sudden cardiac death.

Endocardial Radiofrequency Ablation for Hypertrophic Obstructive Cardiomyopathy: Acute Results and 6 Months' Follow-Up in 19 Patients

OBJECTIVES The purpose of this study was to examine the efficacy and safety of endocardial radiofrequency ablation of septal hypertrophy (ERASH) for left ventricular outflow tract (LVOT) gradient reduction in hypertrophic obstructive cardiomyopathy (HOCM). BACKGROUND Anatomic variability of the vessels supplying the obstructing septal bulge can limit the efficacy of transcoronary ablation of septal hypertrophy in HOCM. Previous studies showed that inducing a local contraction disorder without reducing septal mass results in effective gradient reduction. We examined an alternative endocardial approach to transcoronary ablation of septal hypertrophy by using ERASH. METHODS Nineteen patients with HOCM were enrolled; in 9 patients, the left ventricular septum was ablated, and in 10 patients, the right ventricular septum was ablated. Follow-up examinations (echocardiography, 6-min walk test, bicycle ergometry) were performed 3 days and 6 months after ERASH. RESULTS After 31.2 ± 10 radiofrequency pulses, a significant and sustained LVOT gradient reduction could be achieved (62% reduction of resting gradients and 60% reduction of provoked gradients, p = 0.0001). The 6-min walking distance increased significantly from 412.9 ± 129 m to 471.2 ± 139 m after 6 months, p = 0.019); and New York Heart Association functional class was improved from 3.0 ± 0.0 to 1.6 ± 0.7 (p = 0.0001). Complete atrioventricular block requiring permanent pacemaker implantation occurred in 4 patients (21%); 1 patient had cardiac tamponade. CONCLUSIONS ERASH is a new therapeutic option in the treatment of HOCM, allowing significant and sustained reduction of the LVOT gradient as well as symptomatic improvement with acceptable safety by inducing a discrete septal contraction disorder. It may be suitable for patients not amenable to transcoronary ablation of septal hypertrophy or myectomy.

Transcoronary ablation of septal hypertrophy (TASH): a new treatment option for hypertrophic obstructive cardiomyopathy

In 1991, our group started to develop a catheter interventional therapy for hypertrophic obstructive cardiomyopathy (HOCM). The new concept was proposed in 1994. It is based on the conventional PTCA technique with the aim of inducing an artificial myocardial infarction by instillation of 96% ethanol into the most proximally situated septal branch of the left anterior descending coronary artery. This leads to a subaortic contraction disorder with subsequent decrease of the intraventricular pressure gradient, shrinkage of the hypertrophied septal bulge and widening of the outflow tract (“therapeutic remodeling”). The subaortic defect is small and well demarcated as assessed by left ventricular angiography, transesophageal echocardiography and 18 F-glucose positron emission tomography. The term transcoronary ablation of septum hypertrophy (TASH) was suggested. Our patient cohort that now comprises 215 therapeutic procedures in 187 patients underwent a large variety of prospective studies (maximum follow-up 4.5 years) including invasive controls at regular intervals, investigation of hemodynamics at rest and at exercise, transesophageal and transthoracic echocardiography. Doppler echocardiography during bicycle exercise, electrophysiologic testing, Holter monitoring and measurement of myocardial metabolism and perfusion, assessment of microembolic events by transcranial Doppler sonography and histological examinations. This article gives an overview and reports our increasing experience in applying TASH. The following post-TASH findings were obtained: significant hemodynamic and clinical improvement at rest and at exercise, decrease of septum thickness, increase of outflow tract area and decrease of induced ventricular tachycardia. There were well-demarcated, histologically atypical subaortic myocardial defects, no microembolic events, abnormal early peak of infarct related enzymes, and no change of baroreflex sensitivity. Pre-/post-TASH evaluations of the patients should be based in particular on clinical symptoms correlated to the intraventricular gradient measured by bicycle exercise Doppler echocardiography and to outflow tract area as assessed by transesophageal echocardiography. Since 1994, as a roughly estimate, worldwide 1000 patients in 20 countries have been treated. According to published articles, abstract presentations and workshops, TASH consistently leads to a pronounced clinical and hemodynamic benefit for patients with HOCM. TASH has become an established technique. At least in centers with a high level of expertise, it is no longer experimental but a routinely performed alternative to surgical treatment for HOCM, i.e., the previous gold standard of therapy. Of course, patient outcome needs further careful clinical and prognostic evaluation. With respect to complications, TASH appears to be superior to surgery (transaortic septal myectomy) for HOCM. Like surgical treatment, TASH is currently indicated in critically ill patients with typical HOCM (subaortic form), who exhibit with drug refractory symptoms, including patients, who preferred DDD pacemaker therapy as a first therapeutic step but in whom this produced no subsequent clinical benefit.

Catheter-based therapy for hypertrophic obstructive cardiomyopathy. First in-hospital outcome analysis of the German TASH Registry.

Registerergebnisse einer Katheterbehandlung der HOCM stehen bisher nicht zur Verfügung. 1997 wurde durch die Deutsche Gesellschaft für Kardiologie das nationale, multizentrische TASH-Register (Transkoronare Ablation der Septum-Hypertrophie-Register) von HOCM-Patienten eingeführt, die mit der neuen katheterinterventionellen Methode behandelt wurden. Erstmals wird über die Akutergebnisse während des Aufenthaltes der Patienten im Krankenhaus berichtet, die in den ersten beiden Jahren nach Einführung des Registers erfasst wurden. Es wurde eine Datenbank etabliert. Die Rekrutierung erfolgte auf Intention to treat Basis und sah insgesamt 86 Variable auf drei Standard Formularen vor. Zehn Zentren nahmen teil. Schriftliche Formulardaten standen von 264 Patienten zur Verfügung aus einer Gesamtgruppe von 279 Patienten, die bis Januar 2000 gemeldet wurden. Die Patienten waren im Mittel 3,6±3,9 Jahre medikamentös behandelt worden. Die Mehrzahl der registrierten Patienten (91%) stammte aus drei Zentren. Als Stress-Methode wurden der Valsalva- Versuch oder die Belastungs- Doppler-Echokardiographie verwendet. Die Belastungs-Doppler- Echokardiographie führte zu einer signifikant stärkeren Zunahme des Druckgradienten (70,1% vs. 133,4%, p<0,01). Die Katheterintervention erfolgte in 50,8% Echokontrast gesteuert, in 49,2% der Patienten Druck-Angiographie gesteuert. Im Mittel wurden 2,8±1,3 ml Alkohol injiziert. Vor der Behandlung betrug der invasiv gemessene Gradient 60,4±38,6 mmHg in Ruhe und 142,7±46,2 mmHg postextrasystolisch. Bei Beendigung des Eingriffs war er um 75% bzw. 67% reduziert. Die maximale Aktivität der Phosphokreatin-Kinase im Serum betrug 482,5±264,4 U/L. Gravierende Komplikationen traten in 15,6% auf einschließlich einer Mortalität von 1,2% und einer Schrittmacher-Implantationsrate wegen totalen av-Blocks in 9,6%. Es kam zu einer frühzeitigen Besserung der Luftnot bei Belastung entsprechend einer Abnahme des NYHA-Stadiums von 2,8±0,7 auf 1,8±0,6 (p<0,01). Bei Patienten mit und ohne Ruhegradient zeigte sich eine gleich klinische und hämodynamische Verbesserung. Erstmals steht eine auf Registerbasis vorgenommene Datenanalyse von HOCM-Patienten zur Verfügung, die mittels der neuen Kathetermethode behandelt wurden. Sie ermöglicht einen umfassenden Überblick über klinische Daten, Technik, periinterventionelle Ergebnisse und Komplikationen bei einer großen Zahl von Patienten. Die Ergebnisse tragen wesentlich zur kritischen Beurteilung und Validierung der neuen Methode bei. Sie unterstützen bisherige Ergebnisse, nach denen die Katheterbehandlung der HOCM als Alternative zur herzchirurgischen Behandlung eine neue therapeutische Option bei sehr symptomatischen HOCM-Patienten darstellt. Sie erwies sich sowohl bei Patienten mit als auch bei Patienten ohne intraventrikulärem Druckgradienten in Ruhe als effektiv. Registry results of the new catheter-based method in the treatment for HOCM are missing so far. In 1997, the Transcoronary Ablation of Septal Hypertrophy Registry (TASH Registry) was established by the German Cardiac Society (GCS) as a multicenter, national registry of patients with HOCM undergoing the new catheter interventional therapy. This is the report of the in-hospital outcome of patients who underwent the procedure during the first two years of data collection in the registry. Information was based on three standard forms for each patient, with a total of 86 variables. Information was collected on an “intention to treat” basis. The TASH Registry includes the establishment of a data base in the data collecting center. Ten centers participated. Enrollment forms were received for 264 patients out of 279 patients registered up to January 2000. There was a history of medical treatment of 3.6±3.9 years. The vast majority of patients (91%) were treated in three centers. The Vasalva maneuver and the exercise Doppler echocardiography were used for noninvasive stress testing. Exercise Doppler echocardiography induced a significantly higher augmentation of the baseline gradient (70.1% vs 133.4%; p<0.01). The echo-contrast guided technique was used for the intervention in 50.8% and the pressureangiography guided technique in 49.2%. On the average 2.8±1.3 ml of alcohol were injected. Before the procedure, the gradient measured by catheterization was 60.4±38.6 mmHg at baseline and 142.7±46.2 mmHg following the extrasystolic beat. At the end of the session it was reduced significantly by 75% and 67%. The peak phosphocreatine kinase activity was 482.5±246.4 U/L. Major complications occurred in 15.6% including a mortality rate of 1.2% and a permanent pacemaker implantation rate because of total heart block in 9.6%. There was an early in-hospital improvement of dyspnoe corresponding to a significant decrease of NYHA functional class from 2.8±0.7 to 1.8±0.6 (p<0.001). Similar hemodynamic and clinical benefit was found in patients with and without resting gradient at baseline. This analysis for the first time gives a comprehensive overview of clinical characteristics, technique, procedural data, in-hospital outcome and complications in a large number of patients with HOCM who were treated by the new catheter-based method and prospectively enrolled in a registry. The results contribute considerably to critical evaluation and validation of the new technique. This analysis supports the catheter-based method to constitute a new therapeutic option for very symptomatic patients, to be effective both in patients with and without intraventricular pressure gradient at rest and to be an alternative to surgical treatment, as has been stated recently.

Catheter-based septal ablation for symptomatic hypertrophic obstructive cardiomyopathy: follow-up results of the TASH-registry of the German Cardiac Society.

Im Herbst 1997 richtete die Deutsche Gesellschaft für Kardiologie ein bundesweites Register ein, das den Hospital- und mittelfristigen Verlauf bei mittels perkutaner Septumablation behandelten Patienten (Pat.) mit hypertropher obstruktiver Kardiomyopathie (HOCM) erfassen sollte. Die Analyse des Hospitalverlaufs liegt inzwischen vor. Wir berichten jetzt über den mittelfristigen Verlauf (3–6 Monate) der bis September 1999 eingeschlossenen Patienten. Rückmeldungen lagen für 222 von 242 initial erfassten Pat. vor (92%). Im Follow-up-Zeitraum (4,9±2,3 Monate) verstarben 3 weitere Pat. (Hospitalmortalität: 3 Pat. (1,2%)). Über einen zufriedenstellenden Effekt der Intervention berichteten 195 Pat. (88%). Die akut erreichte Senkung des LVOT-Gradienten (LVOTG) von 57±31 auf 25±25 mmHg in Ruhe und von 107±53 auf 49±40 mmHg unter Provokation war nach 3–6 Monaten weiter akzentuiert (auf 20±21 mmHg in Ruhe bzw. 44±40 mmHg unter Provokation, p sämtlich <0,001), was für ein zeitabhängiges lokales Remodeling im Bereich der septalen Zielregion spricht. LA-Diameter (von 46±8 auf 44±7 mm), Septumdicke (von 20±5 auf 15±5 mm) und Dyspnoe, klassifiziert nach NYHA (von 2,8±0,7 auf 1,7±0,7) nahmen ebenfalls ab (p jew. <0,001). Interventionen unter Einschluss der intra-prozeduralen Echokardiographie sowie solche mit angiographisch/ durch Druckmessung erfolgender Steuerung waren hinsichtlich der klinischen Besserung und der invasiven Resultate vergleichbar. Im mittelfristigen Verlauf nach Kathetertherapie, sowohl kontrastechokardiographisch wie auch per Druckmessung/fluoroskopisch gesteuert, bestätigen sich die positiven Akutergebnisse mit einem weiteren Absinken des LVOTG. LA-Last und Septumdicke nehmen ab, die körperliche Belastbarkeit nimmt weiter zu. In late 1997, the German Cardiac Society set up a multicenter registry to evaluate the acute and mid-term course of all patients (pts.) treated with septal ablation for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). An analysis of the acute results has already been published. We now report on the mid-term course (3–6 months) of 242 pts. registered through September 1999. Follow-up was 92% complete (n=222). During follow-up (mean: 4.9±2.3 months), an additional 3 pts. died (in-hospital mortality: 3 pts.). A satisfactory clinical effect was reported by 195 pts. (88%); 27 pts. (12%) remained in NYHA classes III and IV. Overall symptomatic improvement (NYHA class: from 2.8±0.7 to 1.7±0.7) paralleled the outflow gradient (LVOTG) reduction which was further accentuated as compared with the acute result (Doppler measurement at rest: from 57±31 to 25±25 mmHg to 20±21 mmHg; with provocation: from 107±53 to 49±40, to 44±40 mmHg, p<0.001, resp.). Left atrial (LA) diameter (from 46±8 to 44±7 mm) and septal thickness (from 20±5 to 15±5 mm; p<0.001, resp.) were also reduced. Comparing the methods for target vessel selection (i.e., with contrast echo monitoring vs pressurefluoroscopy guidance), at followup clinical improvement and hemodynamic measurements were comparable. Clinical success can be achieved by septal ablation, both with the echocontrast guided and gradient-fluoroscopy guided method, in 88% of highly symptomatic HOCM pts. At mid-term follow-up, symptoms, left atrial size and septal thickness are reduced, and outflow gradients are further improved as compared to the acute result.

Catheter-based therapy for hypertrophic obstructive cardiomyopathy

Registerergebnisse einer Katheterbehandlung der HOCM stehen bisher nicht zur Verfügung. 1997 wurde durch die Deutsche Gesellschaft für Kardiologie das nationale, multizentrische TASH-Register (Transkoronare Ablation der Septum-Hypertrophie-Register) von HOCM-Patienten eingeführt, die mit der neuen katheterinterventionellen Methode behandelt wurden. Erstmals wird über die Akutergebnisse während des Aufenthaltes der Patienten im Krankenhaus berichtet, die in den ersten beiden Jahren nach Einführung des Registers erfasst wurden. Es wurde eine Datenbank etabliert. Die Rekrutierung erfolgte auf Intention to treat Basis und sah insgesamt 86 Variable auf drei Standard Formularen vor. Zehn Zentren nahmen teil. Schriftliche Formulardaten standen von 264 Patienten zur Verfügung aus einer Gesamtgruppe von 279 Patienten, die bis Januar 2000 gemeldet wurden. Die Patienten waren im Mittel 3,6±3,9 Jahre medikamentös behandelt worden. Die Mehrzahl der registrierten Patienten (91%) stammte aus drei Zentren. Als Stress-Methode wurden der Valsalva- Versuch oder die Belastungs- Doppler-Echokardiographie verwendet. Die Belastungs-Doppler- Echokardiographie führte zu einer signifikant stärkeren Zunahme des Druckgradienten (70,1% vs. 133,4%, p<0,01). Die Katheterintervention erfolgte in 50,8% Echokontrast gesteuert, in 49,2% der Patienten Druck-Angiographie gesteuert. Im Mittel wurden 2,8±1,3 ml Alkohol injiziert. Vor der Behandlung betrug der invasiv gemessene Gradient 60,4±38,6 mmHg in Ruhe und 142,7±46,2 mmHg postextrasystolisch. Bei Beendigung des Eingriffs war er um 75% bzw. 67% reduziert. Die maximale Aktivität der Phosphokreatin-Kinase im Serum betrug 482,5±264,4 U/L. Gravierende Komplikationen traten in 15,6% auf einschließlich einer Mortalität von 1,2% und einer Schrittmacher-Implantationsrate wegen totalen av-Blocks in 9,6%. Es kam zu einer frühzeitigen Besserung der Luftnot bei Belastung entsprechend einer Abnahme des NYHA-Stadiums von 2,8±0,7 auf 1,8±0,6 (p<0,01). Bei Patienten mit und ohne Ruhegradient zeigte sich eine gleich klinische und hämodynamische Verbesserung. Erstmals steht eine auf Registerbasis vorgenommene Datenanalyse von HOCM-Patienten zur Verfügung, die mittels der neuen Kathetermethode behandelt wurden. Sie ermöglicht einen umfassenden Überblick über klinische Daten, Technik, periinterventionelle Ergebnisse und Komplikationen bei einer großen Zahl von Patienten. Die Ergebnisse tragen wesentlich zur kritischen Beurteilung und Validierung der neuen Methode bei. Sie unterstützen bisherige Ergebnisse, nach denen die Katheterbehandlung der HOCM als Alternative zur herzchirurgischen Behandlung eine neue therapeutische Option bei sehr symptomatischen HOCM-Patienten darstellt. Sie erwies sich sowohl bei Patienten mit als auch bei Patienten ohne intraventrikulärem Druckgradienten in Ruhe als effektiv. Registry results of the new catheter-based method in the treatment for HOCM are missing so far. In 1997, the Transcoronary Ablation of Septal Hypertrophy Registry (TASH Registry) was established by the German Cardiac Society (GCS) as a multicenter, national registry of patients with HOCM undergoing the new catheter interventional therapy. This is the report of the in-hospital outcome of patients who underwent the procedure during the first two years of data collection in the registry. Information was based on three standard forms for each patient, with a total of 86 variables. Information was collected on an “intention to treat” basis. The TASH Registry includes the establishment of a data base in the data collecting center. Ten centers participated. Enrollment forms were received for 264 patients out of 279 patients registered up to January 2000. There was a history of medical treatment of 3.6±3.9 years. The vast majority of patients (91%) were treated in three centers. The Vasalva maneuver and the exercise Doppler echocardiography were used for noninvasive stress testing. Exercise Doppler echocardiography induced a significantly higher augmentation of the baseline gradient (70.1% vs 133.4%; p<0.01). The echo-contrast guided technique was used for the intervention in 50.8% and the pressureangiography guided technique in 49.2%. On the average 2.8±1.3 ml of alcohol were injected. Before the procedure, the gradient measured by catheterization was 60.4±38.6 mmHg at baseline and 142.7±46.2 mmHg following the extrasystolic beat. At the end of the session it was reduced significantly by 75% and 67%. The peak phosphocreatine kinase activity was 482.5±246.4 U/L. Major complications occurred in 15.6% including a mortality rate of 1.2% and a permanent pacemaker implantation rate because of total heart block in 9.6%. There was an early in-hospital improvement of dyspnoe corresponding to a significant decrease of NYHA functional class from 2.8±0.7 to 1.8±0.6 (p<0.001). Similar hemodynamic and clinical benefit was found in patients with and without resting gradient at baseline. This analysis for the first time gives a comprehensive overview of clinical characteristics, technique, procedural data, in-hospital outcome and complications in a large number of patients with HOCM who were treated by the new catheter-based method and prospectively enrolled in a registry. The results contribute considerably to critical evaluation and validation of the new technique. This analysis supports the catheter-based method to constitute a new therapeutic option for very symptomatic patients, to be effective both in patients with and without intraventricular pressure gradient at rest and to be an alternative to surgical treatment, as has been stated recently.

Catheter-based septalablation for symptomatic hypertrophic obstructive cardiomyopathy:

Im Herbst 1997 richtete die Deutsche Gesellschaft für Kardiologie ein bundesweites Register ein, das den Hospital- und mittelfristigen Verlauf bei mittels perkutaner Septumablation behandelten Patienten (Pat.) mit hypertropher obstruktiver Kardiomyopathie (HOCM) erfassen sollte. Die Analyse des Hospitalverlaufs liegt inzwischen vor. Wir berichten jetzt über den mittelfristigen Verlauf (3–6 Monate) der bis September 1999 eingeschlossenen Patienten. Rückmeldungen lagen für 222 von 242 initial erfassten Pat. vor (92%). Im Follow-up-Zeitraum (4,9±2,3 Monate) verstarben 3 weitere Pat. (Hospitalmortalität: 3 Pat. (1,2%)). Über einen zufriedenstellenden Effekt der Intervention berichteten 195 Pat. (88%). Die akut erreichte Senkung des LVOT-Gradienten (LVOTG) von 57±31 auf 25±25 mmHg in Ruhe und von 107±53 auf 49±40 mmHg unter Provokation war nach 3–6 Monaten weiter akzentuiert (auf 20±21 mmHg in Ruhe bzw. 44±40 mmHg unter Provokation, p sämtlich <0,001), was für ein zeitabhängiges lokales Remodeling im Bereich der septalen Zielregion spricht. LA-Diameter (von 46±8 auf 44±7 mm), Septumdicke (von 20±5 auf 15±5 mm) und Dyspnoe, klassifiziert nach NYHA (von 2,8±0,7 auf 1,7±0,7) nahmen ebenfalls ab (p jew. <0,001). Interventionen unter Einschluss der intra-prozeduralen Echokardiographie sowie solche mit angiographisch/ durch Druckmessung erfolgender Steuerung waren hinsichtlich der klinischen Besserung und der invasiven Resultate vergleichbar. Im mittelfristigen Verlauf nach Kathetertherapie, sowohl kontrastechokardiographisch wie auch per Druckmessung/fluoroskopisch gesteuert, bestätigen sich die positiven Akutergebnisse mit einem weiteren Absinken des LVOTG. LA-Last und Septumdicke nehmen ab, die körperliche Belastbarkeit nimmt weiter zu. In late 1997, the German Cardiac Society set up a multicenter registry to evaluate the acute and mid-term course of all patients (pts.) treated with septal ablation for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). An analysis of the acute results has already been published. We now report on the mid-term course (3–6 months) of 242 pts. registered through September 1999. Follow-up was 92% complete (n=222). During follow-up (mean: 4.9±2.3 months), an additional 3 pts. died (in-hospital mortality: 3 pts.). A satisfactory clinical effect was reported by 195 pts. (88%); 27 pts. (12%) remained in NYHA classes III and IV. Overall symptomatic improvement (NYHA class: from 2.8±0.7 to 1.7±0.7) paralleled the outflow gradient (LVOTG) reduction which was further accentuated as compared with the acute result (Doppler measurement at rest: from 57±31 to 25±25 mmHg to 20±21 mmHg; with provocation: from 107±53 to 49±40, to 44±40 mmHg, p<0.001, resp.). Left atrial (LA) diameter (from 46±8 to 44±7 mm) and septal thickness (from 20±5 to 15±5 mm; p<0.001, resp.) were also reduced. Comparing the methods for target vessel selection (i.e., with contrast echo monitoring vs pressurefluoroscopy guidance), at followup clinical improvement and hemodynamic measurements were comparable. Clinical success can be achieved by septal ablation, both with the echocontrast guided and gradient-fluoroscopy guided method, in 88% of highly symptomatic HOCM pts. At mid-term follow-up, symptoms, left atrial size and septal thickness are reduced, and outflow gradients are further improved as compared to the acute result.

Utility of endomyocardial biopsy guided by delayed enhancement areas on magnetic resonance imaging in the diagnosis of cardiac sarcoidosis.

Stefan Röthemeyer, MD Schuechtermann-Klinik Bad Rothenfelde Department of Cardiology Ulmenallee 11 49214 Bad Rothenfelde, Germany Sirs: Sarcoidosis is a multisystem disease of unknown cause, affecting typically the lungs, liver, skin and eyes. Infiltrating non-caseating epitheloid cell granulomas (NCG) is the disease defining histopathological substrate of this inflammatory disease [1]. Cardiac involvement can present as asymptomatic conduction abnormalities, congestive heart failure or fatal ventricular arrhythmias, which determines the overall poor prognosis and underscores the importance of early diagnosis [2]. Treatment consists of immunosuppressive therapy and prevention of sudden cardiac death with implantable defibrillators [3]. Because specific clinical imaging tools are still not available, the demonstration of NCG in myocardial tissue is the gold standard in confirming the diagnosis of cardiac sarcoidosis (CS), especially if no extracardiac involvement is evident [4].