Ventricular Septal Myectomy Decreases Long-Term Risk for Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy

Abstract

Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM) and is an important cause of morbidity and embolic stroke. The impact of outflow obstruction and the influence of surgical septal myectomy on the development of new-onset AF has not been well described. Consecutive patients with HCM without previous AF were followed for 5.0 ± 3.6 years for new-onset AF, including 717 with obstruction who did not undergo surgical myectomy (outflow gradients ≥30 mm Hg at rest or after provocation), 555 with nonobstructive HCM (outflow gradients <30 mm Hg), and 503 who underwent surgical myectomy. Patients with obstructive HCM who did not undergo myectomy had a 1.5-fold increased risk for new-onset AF compared with nonobstructive HCM (26% vs 16% at 10 years, hazard ratio = 0.69, p = 0.02). Patients who underwent myectomy had more advanced heart failure (95% vs 18% New York Heart Association class III, p <0.001) and had larger left atrium dimension (42 ± 7 vs 41 ± 7 mm; p <0.01) as compared with patients with obstructive HCM who did not undergo myectomy. However, after myectomy, the risk of new-onset AF was significantly lower than nonoperated obstructive (17% vs 26% at 10 years, p = 0.04) and no different from the risk of AF in patients with nonobstructive HC (hazard ratio 0.95, p = 0.81). In conclusion, patients with HCM with outflow obstruction are at a higher risk for AF compared with patients with nonobstructive HCM. However, after surgical myectomy, the risk for new-onset AF is substantially reduced. In addition to the known benefits of myectomy to permanently relieve outflow tract obstruction and mitral regurgitation, reverse heart failure symptoms, and increase longevity, myectomy is now shown to decrease susceptibility to AF in HCM.