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Invasive management of left ventricular outflow obstruction in children is challenging but in large, experienced centres, is associated with a low procedural mortality and good long-term outcomes .8,9 The improvement in LVOTG and symptomatic status produced by RFSA superficially resemble those demonstrated in a small adult series with a lower frequency of conduction disease post procedure.10 However, the lowest measured residual gradient in 12 of the 32 patients was 30mmHg or greater following the initial procedure. The authors also present a Kaplan-Meier to demonstrate that freedom from intervention at 10 years was 87.5%, despite 5 of the 32 patients requiring further intervention for LVOTO. Even more concerning is the high complication rate including one periprocedural death and a second death during follow-up.
There are a number of important principles that should be followed when considering patients for invasive treatment of LVOTO in HCM. In particular, invasive treatment should be considered only when the mechanism of symptoms is clearly understood and patients have received aggressive medical therapy. The type of therapy should primarily be determined by myocardial and valvular morphology. From the data presented, clinical profiling and selection criteria were not available. Symptomatic status at the time of intervention was not defined and only symptoms at the time of presentation were provided. Data relating to cardiac morphology was not provided. Without the afore mentioned it is difficult to comment whether patient selection contributed to the rate of re-intervention seen in this study.
During long term follow up 2 patients developed ventricular arrhythmias. A fundamental concern regarding the use of alcohol septal ablation in this age group relates to the production of pro-arrhythmic scar and increased risk of sudden cardiac death. Evaluation of the scar generated by RFSA and its impact on risk is required.
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