Effects of alcohol septal ablation on coronary microvascular function and myocardial energetics in hypertrophic obstructive cardiomyopathy

2011 ◽  
Vol 301 (1) ◽  
pp. H129-H137 ◽  
Author(s):  
Stefan A. J. Timmer ◽  
Paul Knaapen ◽  
Tjeerd Germans ◽  
Pieter A. Dijkmans ◽  
Mark Lubberink ◽  
...  
Keyword(s):  
Microvascular Dysfunction ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Microvascular Function ◽  
Coronary Microvascular Dysfunction ◽  
Alcohol Septal Ablation ◽  
Myocardial Energetics ◽  
Left Ventricular Outflow ◽  
External Efficiency

This study investigated the effects of alcohol septal ablation (ASA) on microcirculatory function and myocardial energetics in patients with hypertrophic cardiomyopathy (HCM) and left ventricular outflow tract (LVOT) obstruction. In 15 HCM patients who underwent ASA, echocardiography was performed before and 6 mo after the procedure to assess the LVOT gradient (LVOTG). Additionally, [15O]water PET was performed to obtain resting myocardial blood flow (MBF) and coronary vasodilator reserve (CVR). Changes in LV mass (LVM) and volumes were assessed by cardiovascular magnetic resonance imaging. Myocardial oxygen consumption (MV̇o2) was evaluated by [11C]acetate PET in a subset of seven patients to calculate myocardial external efficiency (MEE). After ASA, peak LVOTG decreased from 41 ± 32 to 23 ± 19 mmHg ( P = 0.04), as well as LVM (215 ± 74 to 169 ± 63 g; P < 0.001). MBF remained unchanged (0.94 ± 0.23 to 0.98 ± 0.15 ml·min−1·g−1; P = 0.45), whereas CVR increased (2.55 ± 1.23 to 3.05 ± 1.24; P = 0.05). Preoperatively, the endo-to-epicardial MBF ratio was lower during hyperemia compared with rest (0.80 ± 0.18 vs. 1.18 ± 0.15; P < 0.001). After ASA, the endo-to-epicardial hyperemic (h)MBF ratio increased to 1.03 ± 0.26 ( P = 0.02). ΔCVR was correlated to ΔLVOTG ( r = −0.82; P < 0.001) and ΔLVM ( r = −0.54; P = 0.04). MEE increased from 15 ± 6 to 20 ± 9% ( P = 0.04). Coronary microvascular dysfunction in obstructive HCM is at least in part reversible by relief of LVOT obstruction. After ASA, hMBF and CVR increased predominantly in the subendocardium. The improvement in CVR was closely correlated to the absolute reduction in peak LVOTG, suggesting a pronounced effect of LV loading conditions on microvascular function of the subendocardium. Furthermore, ASA has favorable effects on myocardial energetics.

scholarly journals Alcohol Septal Ablation for the Treatment of Hypertrophic Obstructive Cardiomyopathy

2011 ◽  
Vol 9 (2) ◽  
pp. 108 ◽  
Author(s):  
Constantinos O’Mahony ◽  
Saidi A Mohiddin ◽  
Charles Knight ◽  
◽  
◽  
...  
Keyword(s):  
Hypertrophic Cardiomyopathy ◽  
Ventricular Hypertrophy ◽  
Left Ventricular Outflow Tract ◽  
Comprehensive Evaluation ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Alcohol Septal Ablation ◽  
Refractory Symptoms ◽  
Left Ventricular Outflow

Hypertrophic cardiomyopathy (HCM) is an inherited myocardial disorder characterised by left ventricular hypertrophy. A subgroup of patients develops limiting symptoms in association with left ventricular outflow tract obstruction (LVOTO). Current international guidelines recommend that symptomatic patients are initially treated by alleviating exacerbating factors and negatively inotropic medication. Drug-refractory symptoms require a comprehensive evaluation of the mechanism of LVOTO and review by a multidisciplinary team to consider the relative merits of myectomy, alcohol septal ablation (ASA) and pacing. This article provides a brief overview of HCM and the pathophysiology of LVOTO, and reviews the use of ASA in patients with drug-refractory symptoms secondary to LVOTO.

scholarly journals The results of alcoholic septal ablation in the treatment of hypertrophic cardiomyopathy

2020 ◽  
pp. 44-49
Author(s):  
B.M. Todurov ◽  
◽  
G.I. Kovtun ◽  
A.V. Khokhlov ◽  
O.V. Pantazi ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Hypertrophic Cardiomyopathy ◽  
Left Ventricular Outflow Tract ◽  
Young Patients ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Outflow Tract ◽  
Alcohol Septal Ablation ◽  
Left Ventricular Outflow

Hypertrophic obstructive cardiomyopathy іs a relatively common condition and one of the most common causes of sudden cardiac death in young age. One of the options for the surgical treatment of this pathology is septal myoectomy, which has been the gold standard for decades. However, despite this, surgical treatment is intended for young patients with a low risk of postoperative complications, while patients with concomitant diseases and a higher surgical risk require alternative treatment. Today, alcohol septal ablation is considered an effective, minimally invasive method for treating hypertrophic obstructive cardiomyopathy in patients with a left ventricular outflow tract gradient ≥ 50 mm Hg. The article presents the experience of using alcohol septal ablation in 57 patients with obstruction of the left ventricular outflow tract. Key words: alcoholic septal ablation, hypertrophic cardiomyopathy, left ventricular outflow tract obstruction.

scholarly journals Intra-cardiac echocardiography in alcohol septal ablation: a prospective comparative study against trans-thoracic echocardiography

2015 ◽  
Vol 2 (1) ◽  
pp. 9-17 ◽  
Author(s):  
Robert M Cooper ◽  
Adeel Shahzad ◽  
James Newton ◽  
Niels Vejlstrup ◽  
Anna Axelsson ◽  
...  
Keyword(s):  
Left Ventricular Outflow Tract ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Cardiac Anatomy ◽  
Alcohol Septal Ablation ◽  
Adjacent Structures ◽  
Significant Difference ◽  
Left Ventricular Outflow ◽  
Prospective Comparative Study

Alcohol septal ablation (ASA) in hypertrophic obstructive cardiomyopathy reduces left ventricular outflow tract gradients. A third of patients do not respond; inaccurate localisation of the iatrogenic infarct can be responsible. Transthoracic echocardiography (TTE) using myocardial contrast can be difficult in the laboratory environment. Intra-cardiac echocardiography (ICE) provides high-quality images. We aimed to assess ICE against TTE in ASA. The ability of ICE and TTE to assess three key domains (mitral valve (MV) anatomy and systolic anterior motion, visualisation of target septum, adjacent structures) was evaluated in 20 consecutive patients undergoing ASA. Two independent experts scored paired TTE and ICE images off line for each domain in both groups. The ability to see myocardial contrast following septal arterial injection was also assessed by the cardiologist performing ASA. In patients undergoing ASA, ICE was superior in viewing MV anatomy (P=0.02). TTE was superior in assessing adjacent structures (P=0.002). There was no difference in assessing target septum. Myocardial contrast: ICE did not clearly identify the area of contrast in 17/19 patients due to dense acoustic shadowing (8/19) and inadequate opacification of the myocardium (6/19). ICE only clearly localised contrast in 2/19 cases. ICE does not visualise myocardial contrast well and therefore cannot be used to guide ASA. TTE was substantially better at viewing myocardial contrast. There was no significant difference between ICE and TTE in the overall ability to comment on cardiac anatomy relevant to ASA.

The Use of MitraClip for Symptomatic Patients with Hypertrophic Obstructive Cardiomyopathy

Cardiology ◽  
2017 ◽  
Vol 137 (1) ◽  
pp. 58-61 ◽  
Author(s):  
Felix Thomas ◽  
Florian Rader ◽  
Robert J. Siegel
Keyword(s):  
Nyha Class ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Cardiac Conduction ◽  
Published Data ◽  
Alcohol Septal Ablation ◽  
Septal Myectomy ◽  
Conduction Abnormalities ◽  
Left Ventricular Outflow

Objectives: Current nonpharmacological therapies for symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM), including septal myectomy and alcohol septal ablation (ASA), carry significant risks for serious cardiac conduction abnormalities. We present a review of the currently available published data regarding the novel use of the relatively low-risk MitraClip® system in the treatment of symptomatic patients. Methods: Data were collected from 4 separate studies on the use of the MitraClip on 15 symptomatic HOCM patients with systolic anterior motion (SAM) of the mitral valve apparatus. Information regarding the degree of mitral regurgitation (MR), left-ventricular outflow tract (LVOT) gradient, and NYHA class was consolidated. Results: After MitraClip treatment, all patients had a resolution of SAM, a reduction in MR, and a reduction in the LVOT gradient from a mean of 75.8 ± 39.7 to 11.0 ± 5.6 mm Hg. Nearly all patients demonstrated improvements in symptoms by either new NYHA class designations or improved exercise tolerance. The procedure was not associated with conduction abnormalities or arrhythmias. Conclusion: MitraClip therapy may be a safe and effective treatment for symptomatic HOCM patients; it can help to avoid the potential risks associated with alternative therapies in high-risk surgical patients.

scholarly journals Septal Ablation Versus Surgical Myomectomy for Hypertrophic Obstructive Cardiomyopathy

2021 ◽  
Vol 23 (11) ◽  
Author(s):  
F. Pelliccia ◽  
H. Seggewiss ◽  
F. Cecchi ◽  
P. Calabrò ◽  
G. Limongelli ◽  
...  
Keyword(s):  
Clinical Status ◽  
Functional Limitation ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Dramatic Improvement ◽  
Heart Team ◽  
Alcohol Septal Ablation ◽  
Expert Opinions ◽  
Left Ventricular Outflow

Abstract Purpose of Review Patients with hypertrophic cardiomyopathy (HCM) who have left ventricular outflow tract obstruction (LVOTO) often experience severe symptoms and functional limitation. Relief of LVOTO can be achieved by two invasive interventions, i.e., surgery myectomy and alcohol septal ablation (ASA), leading in experienced hands to a dramatic improvement in clinical status. Despite extensive research, however, the choice of the best option in individual patients remains challenging and poses numerous clinical dilemmas. Recent Findings Invasive strategies have been recently incorporated in recommendations for the diagnosis and treatment of HCM on both sides of the Atlantic. These guidelines are based on a bulk of well-designed but retrospective studies as well as on expert opinions. Evidence now exists that adequate evaluation and management of HCM requires a multidisciplinary team capable of choosing the best available options. Summary Management of LVOTO still varies largely based on local expertise and patient preference. Following the trend that has emerged for other cardiac diseases amenable to invasive interventions, the concept of a “HCM heart team” is coming of age.

Transaortic extended left ventricular septal myectomy in an adult with hypertrophic obstructive cardiomyopathy

2020 ◽  
Keyword(s):  
Hypertrophic Cardiomyopathy ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Current Case ◽  
Alcohol Septal Ablation ◽  
Septal Myectomy ◽  
Septal Thickness ◽  
Left Ventricular Outflow ◽  
Maximal Medical Therapy

In symptomatic patients with an obstructive variant of hypertrophic cardiomyopathy and no response to maximal medical therapy, we recommend a septal myectomy. It is considered the gold standard for treatment of the basal variant of hypertrophic cardiomyopathy. It has several advantages over alcohol septal ablation, such as the immediate relief of the obstruction and the ability to reduce the septal thickness significantly, to eliminate the potential for midventricular obstruction, and to rule out any other etiologies of left ventricular outflow tract obstruction, which include the presence of abnormalities in the mitral valve subvalvular apparatus such as the presence of anomalous chords, which occured in the current case, and anomalous papillary muscles. In experienced hands, the technique is safe and is associated with excellent outcomes with improved quality of life and potential for survival benefit.

scholarly journals Clinical comparison of the two invasive treatments of hypertrophic obstructive cardiomyopathy: a systematic review and meta-analysis

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
I Bytyci ◽  
G Bajraktari ◽  
M.Y Henein
Keyword(s):  
Left Ventricular Outflow Tract ◽  
Clinical Symptoms ◽  
Meta Analysis ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Outflow Tract ◽  
Alcohol Septal Ablation ◽  
Left Ventricular Outflow

Abstract Background The two available interventional treatment of patients with hypertrophic obstructive cardiomyopathy aresurgical myectomy (SM) and Alcohol septal ablation (ASA). The aim of this meta-analysis was to assess the efficacity of these two invasive strategies in relieving symptoms and left ventricular outflow tract obstruction (LVOTO). Methods We searched PubMed, EMBASE, Scopus, Google Scholar and Cochrane Central until February 2020 for RCTs and cohorts comparing clinical outcomes with alcohol septal ablation (ASA) vs surgical myectomy (SM) in patients with HCM. The endpoints were relieving symptoms, reduced left ventricular outflow tract obstruction (LVOTO) and the need for reintervention. Results We included 20 studies (n=4547; 3 RCTs and 17 cohorts) comparing ASA vs MS for a mean follow-up 5.2±2.1 year. Baseline mean LVOT gradient was not different between the ASA and the MS patient groups with weighted mean difference (WMD) = 1.50 [−3.47 to 6.46, p=0.56]. During follow-up, SM patients showed greater reduction in the LVOT gradient compared to ASA WMD = −9.61 [CI, 4.71 to 14.50, p=0.0001]. In addition, SM group had greater resolution of clinical symptoms compared to ASA (NYHA class III/IV, 17% vs. 6.2% R: 2.76, CI, 1.64 to 4.64, p&lt;0.001, angina 46% vs. 15.7%, RR: 2.79 [CI, 1.14 to 6.82, p=0.02) and lower reinterventions (10.1% vs. 0.02%; RR=15.1, 95% CI: 6.10 to 37.1 p&lt;0.001). Conclusion Compared with alcohol septal ablation, septal myectomy treatment of hypertrophic obstructive cardiomyopathy is associated with greater resolution of clinical symptoms and less need for reintervention. Funding Acknowledgement Type of funding source: None

scholarly journals Ten Tips and Tricks for Performing Alcohol Septal Ablation in Patients with Hypertrophic Obstructive Cardiomyopathy

2020 ◽  
Vol 29 (03) ◽  
pp. 180-182
Author(s):  
Josef Veselka
Keyword(s):  
Therapeutic Strategy ◽  
Left Ventricular Outflow Tract ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Outflow Tract ◽  
Tips And Tricks ◽  
Alcohol Septal Ablation ◽  
Ventricular Outflow Tract Obstruction ◽  
Left Ventricular Outflow

AbstractAlcohol septal ablation (ASA) is an effective interventional therapeutic strategy to reduce or eliminate left ventricular outflow tract obstruction in patients with hypertrophic obstructive cardiomyopathy (HOCM). Although ASA was introduced 25 years ago, there are still no available guidelines to follow. Therefore, most interventional cardiologists rely on their own experience, which is often limited by a relatively low number of performed procedures. This paper presents ten tips and tricks to safe and effective ASA for HOCM.

scholarly journals Myectomy versus alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy

2020 ◽  
Vol 31 (2) ◽  
pp. 158-165
Author(s):  
Alexander V Afanasyev ◽  
Alexander V Bogachev-Prokophiev ◽  
Maxim G Kashtanov ◽  
Dmitriy A Astapov ◽  
Anton S Zalesov ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Left Ventricular Outflow Tract ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Outflow Tract ◽  
Class Iii ◽  
Alcohol Septal Ablation ◽  
Septal Myectomy ◽  
Left Ventricular Outflow

Abstract OBJECTIVES There is very little evidence comparing the safety and efficacy of alcohol septal ablation versus septal myectomy for a septal reduction in patients with hypertrophic obstructive cardiomyopathy. This study aimed to compare the immediate and long-term outcomes of these procedures. METHODS Following propensity score matching, we retrospectively analysed outcomes in 105 patients who underwent myectomy and 105 who underwent septal ablation between 2011 and 2017 at 2 reference centres. RESULTS The mean age was 51.9 ± 14.3 and 52.2 ± 14.3 years in the myectomy and ablation groups, respectively (P = 0.855), and postoperative left ventricular outflow tract gradients were 13 (10–19) mmHg vs 16 (12–26) mmHg; P = 0.025. The 1-year prevalence of the New York Heart Association class III–IV was higher in the ablation group (none vs 6.4%; P = 0.041). The 5-year overall survival rate [96.8% (86.3–99.3) after myectomy and 93.5% (85.9–97.1) after ablation; P = 0.103] and cumulative incidence of sudden cardiac death [0% and 1.9% (0.5–7.5), respectively P = 0.797] did not differ between the groups. The cumulative reoperation rate within 5 years was lower after myectomy than after ablation [2.0% (0.5–7.6) vs 14.6% (8.6–24.1); P = 0.003]. Ablation was associated with a higher reoperation risk (subdistributional hazard ratio = 5.9; 95% confidence interval 1.3–26.3, P = 0.020). At follow-up, left ventricular outflow tract gradient [16 (11–20) vs 23 (15–59) mmHg; P &lt; 0.001] and prevalence of 2+ mitral regurgitation (1.1% vs 10.6%; P = 0.016) were lower after myectomy than after ablation. CONCLUSIONS Both procedures improved functional capacity; however, myectomy better-resolved classes III–IV of heart failure. Septal ablation was associated with higher reoperation rates. Myectomy demonstrated benefits in gradient relief and mitral regurgitation elimination. The results suggest that decreasing rates of myectomy procedures need to be investigated and reconsidered.

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