Golden jubilee of hypertrophic cardiomyopathy: is alcohol septal ablation the gold standard?

doi:10.1016/j.carrev.2009.02.006

Cardiovascular Revascularization Medicine

Volume 10, Issue 3, July–September 2009, Pages 172-178

https://doi.org/10.1016/j.carrev.2009.02.006 Get rights and content

Abstract

In the golden jubilee year of the first recognition of hypertrophic obstructive cardiomyopathy, we are discussing the intricacies and impact of alcohol septal ablation (ASA) in the treatment of this clinical entity. Since its first revelation 14 years ago, ASA has become a well-established treatment modality for symptomatic hypertrophic obstructive cardiomyopathy patients. With better recognition of the implication of first septal branch and right dose of alcohol to be used for ablation, the incidence of complications like complete heart block are coming down along with better procedural success rates. In appropriately selected patients and in expert hands ASA has produced excellent results. Surgical myectomy, even though it has produced excellent results, is available only at a few centers and patient preference is tilted more for a less invasive procedure like ASA. This has contributed towards far more ASAs being performed worldwide than surgical myectomies. While more than 5000 ASAs have been performed in the last 14 years, the number of patients who have had myectomy remains around 3000–4000. The pendulum of gold standard may have started swinging away from surgical myectomy towards ASA.

Section snippets

The idea

The idea of septal ablation originated in the early 1980s, at the University of Lausanne in Switzerland. While studying the hemodynamics of left-sided cardiac chambers in patients with HOCM, Sigwart and the late Dr. Grbic [5] found significant reduction in left ventricular outflow tract gradient when angioplasty balloon was inflated in the first septal artery. This was further supported by the disappearance of the typical auscultatory findings, carotid pulse, and echocardiographic

Clinico-anatomical correlates

Basal interventricular septal hypertrophy and its related septal arterial branches are the core component of ASA. Recently, Angelini [8] has defined this as a new anatomic-functional entity, the first septal unit. Asymmetric septal hypertrophy (ASH) of the basal interventricular septum and systolic anterior motion (SAM) of the anterior mitral leaflet (AML) are the two most important contributors of the LVOT obstruction (LVOTO). The AML septal contact zone is the main area of interest and the

Patient selection

Appropriate selection of the patient remains vital for the success of ASA. All patients undergoing ASA should be NYHA Class III or IV despite optimal medical therapy or are intolerant to medical therapy. The LVOTO should be >30 mmHg at rest and >50 mmHg on provocation [19], [20], [21]. ASA is largely dependent on the morphology of the first septal unit. Variation in this core structure/absence of a suitable septal perforator may preclude the use of this modality in certain patient population.

The technique

Femoral access is the preferable route for ASA. A temporary transvenous pacemaker lead is placed in the apex of the right ventricle and is kept for 48 h postprocedure. The septum is avoided as the pacing site, because fluctuation in pacing threshold may occur during the procedure due to the proximity of this region to the target area for ASA. Baseline left ventriculogram is performed to assess the mitral regurgitation and the site and extent of hypertrophy. LVOTO is assessed by Doppler

Pathophysiological changes

ASA results in coagulative necrosis of both the myocardium and septal perforator arteries. Affected arteries are filled with necrotic debris and lack platelet-fibrin thrombi. In the later stages, there is a development of dense scar with adjacent area of viable myocytes [32]. Single-photon emission computed tomography imaging following ASA has shown the basal ventricular septal infarcts to be <10% of the LV myocardium. Perfusion abnormality decreases late after ASA without an increase in LVOTO

Clinical outcome of ASA

In a pooled analysis of 42 published studies between 1996 and 2005, Alam et al. [46] have analyzed the outcome of ASA in 2959 patients. After a mean follow-up of 12.7 months, there was a sustained reduction in resting and provocable LVOTO gradients from 65.3 to 15.8 mmHg and from 125.4 to 31.5 mmHg, respectively.

Basal septal diameter decreased from 20.9 to 13.9 mm. This was associated with significant improvement in symptoms and decrease in mean NYHA functional class from 2.9 to 1.2. Mean

Complications

Inhospital mortality ranges from 0% to 4%, and at experienced centers mortality is in a lower range even in high-risk patients [46], [48]. Complete heart block requiring permanent pacemaker is the most important complication associated with ASA. LAD dissection, remote infarction, ventricular fibrillation, stroke, pericardial effusion, and ventricular septal defects are relatively uncommon complications of ASA [46], [51], [52].

Surgery or ablation

Surgical myectomy essentially involves removal of a small segment of hypertrophied basal septum. Both surgical myectomy and ASA have their own advantages and disadvantages (Table 3). The real question remains as to the choice of procedure in a particular patient. There are no randomized controlled trials comparing these two strategies. The studies that have compared the two procedures are nonrandomized and retrospective in nature [62], [63], [64], [65], [66]. The patients undergoing ASA in

Alternate modalities

Recently, various alternative modalities in place of alcohol have been tried in an attempt to reduce the complication rates of ASA. Coils [69], polyvinyl alcohol particles [70], angioplasty wires [71], cyanoacrylate glue [72], gelatin particles [73], and radiofrequency ablation [74] are few such options. A 6-month follow-up of 20 patients after coil embolization of the septal artery has shown a significant reduction in LVOTO (from 80 to 35 mmHg) and a 0% incidence of complete heart block [70].

Conclusions

Half a century after the first well-documented description of HOCM and 14 years after its introduction, ASA has emerged as a safe and effective alternative in the management of symptomatic HOCM. Although the role of ASA vis-à-vis surgery is yet not clear, evaluation of long-term data may help in further defining the role of ASA in the management of HOCM. Given the rarity of the disease, diversity of the patients opting for a particular septal reduction therapy, and patients' inclination for a

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Cited by (8)

Short- and long-term outcome after alcohol septal ablation in obstructive hypertrophic cardiomyopathy: Experience of a reference center
2019, Revista Portuguesa de Cardiologia
Citation Excerpt :
This patient was in NYHA class IV with mid-ventricular obstruction, and the procedure was a palliative intervention. These findings confirm the low mortality associated with this procedure reported in the literature, even in high-risk patients.32,33 In a long follow-up period, we reported all-cause mortality of 7.2% and mortality of cardiac cause of 2.5%.
In obstructive hypertrophic cardiomyopathy (HCM), alcohol septal ablation (ASA) can lead to gradient reduction and symptom improvement. We aimed to assess the efficacy and safety of ASA in a long-term outcome study.
We analyzed patients who underwent ASA over a seven-year period in a tertiary center. The primary echocardiographic endpoint was >50% reduction in left ventricular outflow tract (LVOT) gradient within a year of the procedure. The primary clinical endpoints were improvement in functional capacity and a combined endpoint of cardiac death and rehospitalization for cardiac cause. The follow-up period was 4.17±2.13 years.
A total of 80 patients, mean age 63.9±12.3 years, 30.0% male, were analyzed. Baseline LVOT gradient was 96.3±34.6 mmHg and interventricular septal thickness was 21.6±3.1 mm. Minor complications were observed in 6.3% and major complications in 2.5%, and 8.8% received a permanent pacemaker.
The primary echocardiographic endpoint was achieved by 85.7%. At three-month follow-up, LVOT gradient was 25.8±26.0 mmHg in the successful procedure group, compared to 69.2±35.6 mmHg in the other patients (p=0.001). At six months, LVOT gradient was 27.1±27.4 vs. 58.2±16.6 mmHg (p=0.024). Among 74 patients in NYHA class III/IV before the procedure, 57 (77%) improved to NHYA class I/II. The combined primary clinical endpoint (cardiac death and rehospitalization for cardiac cause) was observed in 27.5% (n=22). In the unsuccessful group, the combined endpoint was observed in 54.5%, compared to only 22.7% in the successful group. Only two patients died of cardiac causes.
ASA is a safe procedure with a high success rate. Patients who achieved significant reductions in LVOT gradient suffered less cardiac death and rehospitalization for cardiac cause.
Na miocardiopatia hipertrófica obstrutiva (MCHO), ablação septal alcoólica (ASA) pode levar a redução do gradiente e melhoria sintomática. O objetivo foi avaliar a eficácia e segurança da ASA no desfecho a longo prazo.
Análise de doentes submetidos a ASA, durante sete anos, num centro terciário. Endpoint primário ecocardiográfico: redução >50% do gradiente na câmara de saída do ventrículo esquerdo (CSVE) durante o primeiro ano após o procedimento. Endpoints primários clínicos: a) melhoria da capacidade funcional; b) endpoint combinado: morte de causa cardíaca+hospitalização de causa cardíaca. Tempo de seguimento 4,17±2,13 anos.
Oitenta doentes, idade média de 63,9±12,3 anos, 30,0% homens. De base, o gradiente na CSVE era 96,3±34,6 mmHg, espessura do septo interventricular 21,6±3,1 mm. Complicações minor foram verificadas em 6,3%, complicações major em 2,5% e 8,8% receberam um pacemaker definitivo. O endpoint primário ecocardiográfico foi atingido em 85,7%. Aos três meses, o gradiente na CSVE foi de 25,8±26,0 mmHg no grupo com sucesso no procedimento contrastando com 69,2±35,6 mmHg nos restantes doentes (p=0,001). Aos seis meses, os gradientes na CSVE foram 27,1±27,4 versus 58,2±16,6 mmHg (p=0,024).
De entre os 74 doentes em classe NYHA III/IV antes do procedimento, 57 (77%) melhoraram para classe NYHA I/II. O endpoint primário combinado (morte de causa cardíaca+hospitalização de causa cardíaca) verificou-se em 27,5% (n=22). No grupo sem sucesso, o endpoint primário composto verificou-se em 54,5%, contrastando com apenas 22,7% no grupo com sucesso. Apenas dois doentes apresentaram morte de causa cardíaca.
A ASA é um procedimento seguro com elevada taxa de sucesso. Doentes que atingiram redução significativa do gradiente na CSVE apresentam menor morte de causa cardíaca e hospitalização de causa cardíaca.
Alcohol septal ablation in a patient with hypertrophic obstructive cardiomyopathy
2014, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Some operators prefer to do TEE a day before the procedure to confirm the diagnosis and rule out membraneous subaortic stenosis, which might mimic HOCM. Some institutions routinely use intraoperative myocardial contrast echocardiography (MCE) to accurately localize the artery supplying the SAM-septal contact area.6 Its use has improved the success and safety of TASH, modifying the interventional approach in up to 20% of cases.10
Alcohol septal ablation in obstructive hypertrophic cardiomyopathy: Four years of experience at a reference center
2014, Revista Portuguesa de Cardiologia
A ablação septal alcoólica (ASA) é a forma percutânea de tratamento invasivo da cardiomiopatia hipertrófica obstrutiva (CMHO). A propósito da descrição da experiência no nosso centro, procurar-se-á rever as indicações, os aspetos técnicos e práticos e os resultados da ASA, assim como a sua posição atual em comparação com a miectomia cirúrgica.
Avaliar os resultados da ASA numa série de doentes consecutivos tratados nos primeiros quatro anos de atividade.
Estudo retrospetivo de todos os doentes, consecutivos e não selecionados, com CMHO, tratados por ASA, entre janeiro de 2009 e fevereiro de 2013.
Durante o período de quatro anos foram tratados com ASA 40 doentes. Em três doentes (7,5%) repetiu-se o procedimento. A taxa de sucesso foi de 84%. A taxa de complicações minor foi de 7,5%. Foi necessário implantar pacemaker definitivo por bloqueio auriculoventricular em dois doentes (6%, do subgrupo sem pacemaker prévio). A taxa de complicações major foi de 5%. Não houve mortalidade intra-hospitalar nesta população. Durante o seguimento clínico (22 ± 14 meses) a mortalidade cardiovascular foi de 2,5%. A mortalidade total foi de 5%.
Os resultados apresentados refletem a experiência inicial do tratamento com ASA no nosso centro. O procedimento foi bem-sucedido na maioria dos doentes, sendo a taxa de sucesso semelhante à descrita em outras séries, mas ainda com possibilidade de beneficiar de uma melhor seleção dos doentes. A intervenção também se revelou segura, com uma baixa ocorrência de complicações e sem mortalidade associada. A ASA é uma alternativa percutânea no tratamento invasivo dos doentes com CMHO refratária à terapêutica médica.
We describe our center's initial experience with alcohol septal ablation (ASA) for the treatment of obstructive hypertrophic cardiomyopathy. The procedure, its indications, results and clinical outcomes will be addressed, as will its current position compared to surgical myectomy.
To assess the results of ASA in all patients treated in the first four years of activity at our center.
We retrospectively studied all consecutive and unselected patients treated by ASA between January 2009 and February 2013.
In the first four years of experience 40 patients were treated in our center. In three patients (7.5%) the intervention was repeated. Procedural success was 84%. Minor complications occurred in 7.5%. Two patients received a permanent pacemaker for atrioventricular block (6% of those without previous pacemaker). The major complication rate was 5%. There were no in-hospital deaths; during clinical follow-up (22±14 months) cardiovascular mortality was 2.5% and overall mortality was 5%.
The results presented reflect the initial experience of our center with ASA. The success rate was high and in line with published results, but with room to improve with better patient selection. ASA was shown to be safe, with a low complication rate and no procedure-related mortality. Our experience confirms ASA as a percutaneous alternative to myectomy for the treatment of symptomatic patients with obstructive hypertrophic cardiomyopathy refractory to medical treatment.
Optimizing Catheter-Based Therapy of Hypertrophic Obstructive Cardiomyopathy: Does Alcohol Dose Matter?
2011, Canadian Journal of Cardiology
The history of alcohol septal ablation
2010, Cardiovascular Revascularization Medicine
Intervention in HCM: Patient selection, procedural approach and emerging techniques in alcohol septal ablation
2015, Echo Research and Practice

View all citing articles on Scopus

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Golden jubilee of hypertrophic cardiomyopathy: is alcohol septal ablation the gold standard?

Abstract

Section snippets

The idea

Clinico-anatomical correlates

Patient selection

The technique

Pathophysiological changes

Clinical outcome of ASA

Complications

Surgery or ablation

Alternate modalities

Conclusions

Asymmetrical hypertrophy of the heart in young adults

Br Heart J

Non-surgical myocardial reduction for hypertrophic obstructive cardiomyopathy

Lancet

Catheter treatment for hypertrophic obstructive cardiomyopathy: for seniors only?

Circulation

Historical perspective and names

Ventricular wall motion during balloon occlusion

Hypertrophic cardiomyopathy, disappearance of auscultatory, carotid pulse, and echocardiographic manifestation of obstruction following myocardial infarction

Chest

Transmural myocardial infarction in hypertrophic cardiomyopathy: a cause of conversion from left ventricular asymmetry and from normal-size to dilated left ventricular cavity

Chest

The “first septal unit” in hypertrophic obstructive cardiomyopathy

Tex Heart Inst J

Blood supply of the human interventricular septum in north-west Indians [published erratum appears in Indian Heart J 1990;42:334]

Indian Heart J

Normal and anomalous coronary arteries in humans

The anatomy of the septal perforating arteries in normal and congenitally malformed hearts

J Thorac Cardiovasc Surg

Anatomy of the first septal perforating artery: a study with implications for ablation therapy for hypertrophic cardiomyopathy

Mayo Clin Proc

The descending septal branch (Bonapace's branch). A case report and literature review of this often forgotten branch. First description in vivo

Eur Heart J

Conduction system abnormalities in patients with obstructive hypertrophic cardiomyopathy following septal reduction interventions

Am J Cardiol

Complete heart block: determinants and clinical impact in patients with hypertrophic obstructive cardiomyopathy undergoing nonsurgical septal reduction therapy

J Am Coll Cardiol

Acute predictors of subacute complete heart block after alcohol septal ablation for obstructive hypertrophic cardiomyopathy

Am J Cardiol

Separate origin of a large septal perforator branch

Cathet Cardiovasc Diagn

Frequency and clinical significance of anomalous origin of septal perforator coronary artery

Am J Cardiol

Eur Heart J

Medical therapy versus interventional therapy in hypertrophic obstructive cardiomyopathy

Curr Control Trials Cardiovasc Med

Efficacy of nonsurgical septal reduction therapy in symptomatic patients with obstructive hypertrophic cardiomyopathy and provocable gradients

Am J Cardiol

Catheter-based septal ablation for patients with hypertrophic cardiomyopathy

Simultaneous percutaneous treatment in hypertrophic obstructive cardiomyopathy and coronary artery disease: a case report

Cathet Cardiovasc Diagn

Transcatheter alcohol ablation of the septum in a patient of hypertrophic obstructive cardiomyopathy

Cathet Cardiovasc Diagn

Transcatheter alcohol ablation of the septum in hypertrophic cardiomyopathy

Tex Heart Inst J

Echo-guided percutaneous septal ablation for symptomatic hypertrophic obstructive cardiomyopathy: 7 years of experience

Eur J Echocardiogr

Echocardiography guided ethanol septal reduction for hypertrophic obstructive cardiomyopathy

Circulation

Role of myocardial contrast echocardiography during nonsurgical septal reduction therapy for hypertrophic obstructive cardiomyopathy

J Am Coll Cardiol

Percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: results with respect to intraprocedural myocardial contrast echocardiography

Circulation

Intracardiac echocardiography guidance during percutaneous transluminal septal myocardial ablation in patients with obstructive hypertrophic cardiomyopathy

Int J Cardiovas Interv

Effects of varying ethanol dosing in percutaneous septal ablation for obstructive hypertrophic cardiomyopathy on early hemodynamic changes

Am J Cardiol

Pathological effects of alcohol septal ablation for hypertrophic obstructive cardiomyopathy

Heart

Serial evaluations of myocardial infarct size after alcohol septal ablation in hypertrophic cardiomyopathy and effects of the changes on clinical status and left ventricular outflow pressure gradients

Am J Cardiol.

Septal ablation in hypertrophic obstructive cardiomyopathy improves systolic myocardial function in the lateral (free) wall: a follow-up study using CMR tissue tagging and 3D strain analysis

Eur Heart J

Effect of successful alcohol septal ablation on microvascular function in patients with obstructive hypertrophic cardiomyopathy

Am J Cardiol

Myocardial infarction induced by alcohol septal ablation for hypertrophic cardiomyopathy does not activate platelets

Heart