Alcohol Septal Ablation Versus Surgical Myectomy in Hypertrophic Obstructive Cardiomyopathy

2020 ◽  
Author(s):  
Hussein Taqi
Keyword(s):  
Treatment Modality ◽  
Heart Block ◽  
Invasive Procedure ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Major Surgery ◽  
Muscle Area ◽  
Alcohol Septal Ablation ◽  
Invasive Approach ◽  
Less Invasive ◽  
Surgical Myectomy

The surgical myomectomy for hypertrophied myocardium in patients with HOCM is a well-established and evidence-based treatment modality. However, with the drawback of exposing the patient to major surgery and prolonged post-operative periods, cardiologists together with their surgical peers found the advent of a potentially less invasive procedure. This has been accomplished by the installation of alcohol through the coronary arteries in order to shrink the diseased and hypertrophied muscle area with an aim to alleviate the symptoms in the first instance if not completely curing the pathology as an endeavor goal. Nevertheless, with this invention, a few complications have started to emerge. The main drawback was heart block, which could require permanent pacemaker insertion in most of the cases. In the interim, there is no clear pathway or guideline to decide which treatment option would be the best, and there is no certain inclusion or exclusion criteria incorporate patients who can undergo either one of the modalities. In this review, four studies were scrutinized to investigate the major consequences of each route, especially focusing on the proportion of complete heart block. Also, the role of MRI in the delineation of the resected area either surgically or by alcohol administration is studied in detail. After reviewing these articles, it has been concluded that despite alcohol septal ablation being less invasive approach, surgical therapy remains the preferred treatment modality and it is preferred treatment modality and so far, it is the gold standard option in the management of hypertrophic obstructive cardiomyopathy. Nevertheless, it could not be overlooked the lack of strong RCTS in such area which could be one of the main points that future trialists need to consider.

Is alcohol septal ablation in women performed too late?

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Batzner ◽  
D Aicha ◽  
H Seggewiss
Keyword(s):  
Hospital Stay ◽  
Pacemaker Implantation ◽  
Posterior Wall ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Icd Implantation ◽  
Alcohol Septal Ablation ◽  
Significant Difference ◽  
Surgical Myectomy

Abstract Introduction Alcohol septal ablation (PTSMA) was introduced as interventional alternative to surgical myectomy for symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) 25 years ago. As gender differences in diagnosis and treatment of HOCM are still unclear we analyzed baseline characteristics and results of PTSMA in a large single center cohort with respect to gender. Methods and results Between 05/2000 and 06/2017 first PTSMA in our center was performed in 952 patients with symptomatic HOCM. We treated less 388 (40.8%) women and 564 (59.2%) men. All patients underwent clinical follow-up. At the time of the intervention women were older (61.2±14.9 vs. 51.9±13.7 years; p<0.0001) and suffered more often from NYHA grade III/IV dyspnea (80.9% vs. 68.1%; p<0.0001), whereas angina pectoris was comparable in women (62.4%) and men (59.9%). Echocardiographic baseline gradients were comparable in women (rest 65.0±38.1 mmHg and Valsalva 106.2±45.7 mmHg) and men (rest 63.1±38.3 mmHg and Valsalva 103.6±42.8 mmHg). But, women had smaller diameters of the left atrium (44.3±6.9 vs. 47.2±6.5 mm; p<0001), maximal septum thickness (20.4±3.9 vs. 21.4±4.5 mm; p<0.01), and maximal thickness of the left ventricular posterior wall (12.7±2.8 vs. 13.5±2.9 mm; p<0.0001). In women, more septal branches (1.3±0.6 vs. 1.2±0.5; p<0.05) had to be tested to identify the target septal branch. The amount of injected alcohol was comparable (2.0±0, 4 in women vs. 2.1±0.4 ml in men). The maximum CK increase was lower in women (826.0±489.6 vs. 903.4±543.0 U / l; p<0.05). During hospital stay one woman and one man died, each (n.s.). The frequency of total AV blocks in the cathlab showed no significant difference between women (41.5%) and men (38.3%). Furthermore, the rate of permanent pacemaker implantation during hospital stay did not differ (12.1% in women vs. 9.4% in men). Follow-up periods of all patients showed no significant difference between women (5.7±4.9 years) and men (6.2±5.0 years). Overall, 37 (9.5%) women died during this period compared to only 33 (5.9%) men (p<0.05). But, cardiovascular causes of death were not significantly different between women (2.8%) and men (1.6%). Furthermore, the rates of surgical myectomy after failed PTSMA (1.3% in women vs. 2.3% in men), ICD implantation for primary prevention of sudden cardiac death according to current guidelines (4.1% in women vs. 5.9% in men) or pacemaker implantation (3.6% in women vs. 2.0% in men) showed no significant differences. Summary PTSMA in women with HOCM was performed at more advanced age with more pronounced symptoms compared to men. While there were no differences in acute outcomes, overall long-term mortality was higher in women without differences in cardiovascular mortality. Therefore, women may require more intensive diagnostic approaches in order not to miss the correct time for gradient reduction treatment. Funding Acknowledgement Type of funding source: None

Incidence and Predictors of Late Complete Heart Block After Alcohol Septal Ablation Treatment of Hypertrophic Obstructive Cardiomyopathy

2015 ◽  
Vol 28 (1) ◽  
pp. 90-97 ◽  
Author(s):  
JOSEPH L. SCHULLER ◽  
MATTHEW M. ZIPSE ◽  
MORI J. KRANTZ ◽  
BRIAN BLAKER ◽  
ERNESTO SALCEDO ◽  
...  
Keyword(s):  
Heart Block ◽  
Complete Heart Block ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Alcohol Septal Ablation

scholarly journals Alcohol Septal Ablation: An Option on the Rise in Hypertrophic Obstructive Cardiomyopathy

2021 ◽  
Vol 10 (11) ◽  
pp. 2276
Author(s):  
Victor Arévalos ◽  
Juan José Rodríguez-Arias ◽  
Salvatore Brugaletta ◽  
Antonio Micari ◽  
Francesco Costa ◽  
...  
Keyword(s):  
Interventricular Septum ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Pharmacological Therapy ◽  
Alcohol Septal Ablation ◽  
Invasive Approach ◽  
Septal Myectomy ◽  
All Cause Mortality ◽  
Short And Long Term ◽  
Comprehensive Programs

Hypertrophic cardiomyopathy (HCM) can cause symptoms due to the obstruction of the left ventricle outflow tract (LVOT). Although pharmacological therapy is the first step for treating this condition, many patients do not fully respond to the treatment, and an invasive approach is required to manage symptoms. Septal reduction therapies include septal myectomy (SM) and alcohol septal ablation (ASA). ASA consists of a selective infusion of high-grade alcohol into a septal branch supplying the basal interventricular septum to create an iatrogenic infarction with the aim of reducing LVOT obstruction. Currently, SM and ASA have the same level of indication; however, ASA is normally reserved for patients of advanced age, with comorbidities or when the surgical approach is not feasible. Recent data suggests that there are no differences in short- and long-term all-cause mortality, cardiovascular mortality and sudden cardiac death between ASA and SM. Despite the greater experience and refinement of the technique gained in recent years, the most common complication continues to be complete atrio-ventricular block, requiring a permanent pacemaker. Septal reduction therapies should be performed in experienced centres with comprehensive programs.

scholarly journals Selective Interventricular Septal Radiofrequency Ablation in Patients With Hypertrophic Obstructive Cardiomyopathy: Who Can Benefit?

2021 ◽  
Vol 8 ◽  
Author(s):  
Qiang Liu ◽  
Hangyuan Qiu ◽  
Ruhong Jiang ◽  
Xiaomei Tang ◽  
Wenpu Guo ◽  
...  
Keyword(s):  
Papillary Muscle ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Functional Class ◽  
Mitral Leaflet ◽  
Alcohol Septal Ablation ◽  
Anterior Mitral Leaflet ◽  
Left Ventricular Outflow ◽  
Septal Hypertrophy ◽  
Surgical Myectomy

Introduction: Septal mass reduction is beneficial for hypertrophic obstructive cardiomyopathy (HOCM) patients with severe left ventricular outflow (LVOT) gradient and symptoms, with surgical myectomy or alcohol septal ablation (ASA) currently recommended in selected patients. Radiofrequency (RF) ablation of hypertrophied septum has been published as a novel method to alleviate LVOT obstruction in small populations. This study aims to investigate factors influencing clinical outcomes of radiofrequency septum ablation.Methods and Results: In this study, 20 patients with HOCM who underwent endocardial ablation were included. Echocardiography and cardiac MRI (CMR) data was collected and analyzed pre- and (or) post- procedure. Nineteen patients underwent ablation successfully, while ablation was aborted in one patient with prior RBBB due to transient complete atrioventricular block (AVB). After 6 months of follow-up, NYHA heart functional class improved from III (2 - 3) to II (1 - 2) (p < 0.001), and resting LVOT gradient was significantly reduced (87.6 ± 29.5 mmHg vs. 48.1 ± 29.7, p < 0.001). LVOT gradient reduction was significantly higher in patients with limited basal septal hypertrophy (60.9 ± 8.3 vs. 27.9 ± 7.1, p = 0.01), shorter anterior mitral leaflet (56.1 ± 6.4 vs. 20.4 ± 5.0, p < 0.01), and normally positioned papillary muscle (36.9 ± 7.1 vs. 75.0 ± 6.3, p < 0.05).Conclusions: Endocardial septal ablation appears to be a safe and effective procedure for alleviating LVOT gradient in patients with HOCM, especially in those with limited basal septal hypertrophy, shorter anterior mitral leaflet, and normal positioned papillary muscle.

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