ABC | Volume 112, Nº4, April 2019

Original Article Yang Li Risk factors for PTSMA complications Arq Bras Cardiol. 2019; 112(4):432-438 Table 2 – Univariate analysis of risk factors for related complications of PTSMA Complications (n=66) No Complications (n=158) p value Age (years) 51.27 ± 14.13 46.91 ± 14.28 0.038 Male/female 27/39 92/66 0.000 New York Heart Association functional class 1.10 ± 0.40 1.08 ± 0.33 0.566 CAD 5 8 0.000 Hypertension 19 27 0.000 DM 3 0 0.000 Stroke 1 0 0.122 HR (beats/min) 71.55 ± 11.92 71.08 ± 12.29 0.792 LVOTD (mm) 9.13 ± 2.64 9.33 ± 2.54 0.604 EF 0.63 ± 0.13 0.66 ± 0.08 0.506 Alcohol volume 2.14 ± 0.88 1.85 ± 0.91 0.023 Number of ablation septal 1.19 ± 0.43 1.07 ± 0.27 0.034 CAD: coronary artery disease; DM: diabetes mellitus; HR: heart rate; LVOTD: left ventricular outflow tract diameter; EF: ejection fraction. occurred during the clinical follow-up, except that PTSMA was successfully performed again in one patient for recurrent angina pectoris. The univariate analysis of risk factors for PTSMA-related complications is shown in Table 2. Age, female gender, alcohol volume, the number of septal ablations, comorbidities with CAD, hypertension, and diabetes mellitus (DM) were associated with increased occurrence of complications. Results of the multiple logistic regression analysis are presented in Table 3. In multiple logistic models, except for hypertension (OR: 4.856; 95% CI: 1.732-13.609), age, gender, alcohol volume, the number of septal ablation, comorbidities with CAD, and DM were not potential risk factors for predicting PTSMA-related complications. Table 4 shows the comparisons of clinical characteristics between patients with and without history of hypertension. Female patients appeared to have more cardiovascular risk factors such as hypertension, aging, DM, and history of heart failure in the present study. As listed in Table 5, patients were chronologically divided into three groups according to their experience with PTSMA. In addition, in-hospital complications were more frequent in patients who underwent PTSMA procedures in the early stage (from 2000 to 2004), and less often in patients who unerwent PTSMA procedures later and in experienced time periods (2010-2013) (p = 0.022). Discussion PTSMA is a nonsurgical technique to reduce septal mass by producing a septal infarction using the catheter techniques reported by Sigwart. 4 Permanent septal necrosis is created through the injection of alcohol in the septal branches that supply the myocardium and are responsible for LVOT obstruction induced by abnormal structure and function. This effectively reduces the pressure gradients in patients with HOCM. This technique has the advantage of micro-trauma and high success rate, as well as low mortality (0–1.8%). 13,14 In the present cohort, a successful reduction in LVOTG was achieved in the majority of patients during the procedure (85%) (at rest: from 67.91 ± 37.23 to 16.24 ± 19.13 mmHg, p < 0.01; post premature beat: 119.42 ± 38.44 to 40.83 ± 22.61 mmHg, p < 0.01) and at discharge (96%). However, the occurrence of PTSMA procedure-related complications was notable. In the present study, 14.35% (32/223) of patients had transient complete bundle branch block (32/223), and 0.90% (2/223) of patients had complete left bundle branch block. This phenomenon was consistent with a previous report. 15 The right bundle is usually supplied by proximal septal perforators. Thus, PTMSA frequently leads to complete right bundle branch block. Furthermore, septal myectomy causes complete left bundle branch block in most patients. This is the reason why PTMSA caused more complete right bundle branch and less complete left bundle branch block in our study. Not more than 10% of patients had a high-degree AV block. However, PPM was only performed in four patients (1.79%), which was superior when compared with other PTSMA centers (46% and 38%). 16,17 Serious complications were not uncommon. Except for patient’s death from acute tamponade during the procedure, the most significant complication of the procedure was heart block, 9 which led to the deaths of two patients in our study. One patient had acute severe left ventricular dysfunction during the procedure, while the other patient had heart failure during monitoring in Coronary Care Unit. In addition, reports of in-hospital ventricular fibrillation in relation to PTSMA have attracted considerable attention. 18,19 We found two (0.89%) cases of in-hospital ventricular fibrillation. According to our experience, careful monitoring was indispensable to reducing cardiac adverse events caused by ventricular arrhythmia. As for other serious nonfatal complications, acute myocardial infarction, which was caused by the spill of alcohol into the left anterior descending coronary artery, occurred in one patient. However, no coronary dissection and nonfatal cardiac tamponade occurred. 435