Acute and long-term results after TASH

Acute and long-term results after TASH The authors are to be congratulated for having set up their programme of catheter treatment for hypertrophic obstructive cardiomyopathy with its extensive peri-interventional assessment in a community teaching hospital setting. Several points, however, seem to need clarification and further comment, especially in view of the fact that the work of our group has been directly referred to. (1) As the authors and the accompanying editorial state, the intracavity pressure gradient is just one facet, although an important one, of the complex disease process in hypertrophic obstructive cardiomyopathy. Diastolic dysfunction and rhythm disturbances may determine symptoms and prognosis in the individual patient to a great extent. Besides a proper ablation technique, patient selection is thus essential. With this in mind, it is hard to understand how the elimination of a moderate pressure gradient of <30 mmHg at rest (in 20 out of 50 patients) or even <50 mmHg after premature ventricular contractions (in three patients) may have contributed to a substantial symptomatic improvement. A subgroup analysis of the patients with only moderate obstruction at baseline would have been helpful in clarifying this issue. (2) The procedure-related pacemaker implantation rate approaching 40% seems very high. Since the authors themselves have observed the time course of atrioventricular conduction recovery, and since our group has repeatedly reported on a scoring system that allows a risk stratification with respect to the likelihood of pacemaker dependency vs conduction recovery, the pacemaker implantation rate should have come down to <10%. Not only in terms of haemodynamic efficacy, but also with respect to atrioventricular conduction lesions, surgical myectomy with a pacemaker rate of about 5% should be considered the standard.