Percutaneous septal ablation with absorbable gelatin sponge in hypertrophic obstructive cardiomyopathy

Alcohol Septal Ablation in Patients with Hypertrophic Obstructive Cardiomyopathy: A Contemporary Perspective

Alcohol septal ablation is a minimally invasive procedure for the treatment of left ventricular outflow tract (LVOT) obstruction in patients with hypertrophic obstructive cardiomyopathy (HOCM) who remain symptomatic despite optimal medical therapy. The procedure causes a controlled myocardial infarction of the basal portion of the interventricular septum by the injection of absolute alcohol with the aim of reducing LVOT obstruction and improving the patient's hemodynamics and symptoms. Numerous observations have demonstrated the efficacy and safety of the procedure, making it a valid alternative to surgical myectomy. In particular, the success of alcohol septal ablation depends on appropriate patient selection and the experience of the institution where the procedure is performed. In this review, we summarize the current evidence on alcohol septal ablation and highlight the importance of a multidisciplinary approach involving a team of clinical and interventional cardiologists and cardiac surgeons with high expertise in the management of HOCM patients-the Cardiomyopathy Team.

Safety and efficacy of coil embolization of the septal perforator for septal ablation in patients with hypertrophic obstructive cardiomyopathy

OBJECTIVE

The objective of this study was to evaluate safety, efficacy, and durability of coil embolization of the major septal perforator of the left anterior descending coronary artery in patients with hypertrophic obstructive cardiomyopathy (HOCM).

BACKGROUND

The long-term effect of coil embolization therapy in HOCM patients is not well defined.

METHODS

We evaluated 24 symptomatic HOCM patients in a single center who underwent coil embolization of the septal perforator artery(ies).

RESULTS

Twenty-four patients on optimal medical therapy presented with NYHA functional class III (75%) or IV (25%) underwent the procedure. The procedure was successful in 22 patients, with significant reduction in left ventricular outflow tract (LVOT) gradient. The functional class significantly improved to class I (54.2%) or II (41.7%) (P < = 0.01). The LVOT gradient was significantly lower during follow up echocardiography (21.3 ± 19 vs. 81.3 ± 41 mm Hg; P < = 0.01). Interventricular septal thickness decreased over time (16.3 ± 3 vs. 18.5 ± 2 mm, P< = 0.01). The procedure was aborted in one of the patients after the third coil prolapsed from the septal perforator in to the left anterior descending artery. The coil was effectively snared out. Three patients required additional coil placement in the second major septal perforator. New permanent pacemaker placement was required in one patient. However, three patients underwent ICD implantation at follow up due to ventricular arrhythmias.

CONCLUSIONS

The results of this study suggest that the use of coil embolization for septal ablation is safe, effective, and durable in patients with symptomatic HOCM. © 2016 Wiley Periodicals, Inc.

Glue septal ablation: A promising alternative to alcohol septal ablation

Hypertrophic cardiomyopathy (HCM) is defined as myocardial hypertrophy in the absence of another cardiac or systemic disease capable of producing the magnitude of present hypertrophy. In about 70% of patients with HCM, there is left ventricular outflow tract (LVOT) obstruction (LVOTO) and this is known as obstructive type of hypertrophic cardiomyopathy (HOCM). Cases refractory to medical treatment have had two options either surgical septal myectomy or alcohol septal ablation (ASA) to alleviate LVOT gradient. ASA may cause some life-threatening complications including conduction disturbances and complete heart block, hemodynamic compromise, ventricular arrhythmias, distant and massive myocardial necrosis. Glue septal ablation (GSA) is a promising technique for the treatment of HOCM. Glue seems to be superior to alcohol due to some intrinsic advantageous properties of glue such as immediate polymerization which prevents the leak into the left anterior descending coronary artery and it is particularly useful in patients with collaterals to the right coronary artery in whom alcohol ablation is contraindicated. In our experience, GSA is effective and also a safe technique without significant complications. GSA decreases LVOT gradient immediately after the procedure and this reduction persists during 12 months of follow-up. It improves New York Heart Association functional capacity and decrease interventricular septal wall thickness. Further studies are needed in order to assess the long-term efficacy and safety of this technique.

Controversies in cardiovascular medicine. Hypertrophic obstructive cardiomyopathy: alcohol septal ablation

Alcohol septal ablation (ASA) was introduced in 1994 as an alternative to septal myectomy for patients with hypertrophic obstructive cardiomyopathy and symptoms refractory to medical therapy. This procedure alleviates symptoms by producing a targeted, limited infarction of the upper interventricular septum, resulting in an increase in left ventricular outflow tract (LVOT) diameter, a decrease in LVOT gradient, and regression of the component of LV hypertrophy that is due to pressure overload. Clinical success, with improvement in symptoms and reduction in gradient, is achieved in the great majority of patients with either resting or provocable LVOT obstruction. The principal morbidity of the procedure is complete heart block, resulting in some patients in the requirement for a permanent pacemaker. The introduction of myocardial contrast echocardiography as a component of the ASA procedure has contributed to the induction of smaller myocardial infarctions with lower dosages of alcohol and, in turn, fewer complications. Non-randomized comparisons of septal ablation and septal myectomy have shown similar mortality rates and post-procedure New York Heart Association class for the two procedures.