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Cardiac Hypertrophy, Heart Failure and Cardiomyopathy
Published in Mary N. Sheppard, Practical Cardiovascular Pathology, 2022
Percutaneous transluminal septal myocardial ablation, otherwise known as alcohol septal ablation was introduced in 1990s as an alternative septal reduction therapy at a time when the operative mortality from septal myectomy was much higher than it is today. The procedure is minimally invasive and is performed via the same approach as cardiac catheterization and coronary angiography, with injection of ethanol into the first or second septal perforator of the left anterior descending artery. Ethanol induces an iatrogenic myocardial infarction in the distribution of the basal septum and results in long-term remodelling to abolish obstruction of the LVOT. Since its introduction, this has become an increasingly popular option for septal reduction therapy, such that the number of ablations performed in the last decade exceeds the number of myectomies done in the last half century. There has been concern regarding the arrhythmogenic potential due to the iatrogenic infarction that encompasses approximately 10% of the left ventricular mass following septal ablation and intraprocedural and postprocedural rates of complete heart block have been as high as 20%, with the need for permanent pacemaker implantation.
Congestive Heart Failure
Published in Jahangir Moini, Matthew Adams, Anthony LoGalbo, Complications of Diabetes Mellitus, 2022
Jahangir Moini, Matthew Adams, Anthony LoGalbo
Invasive treatment is needed for patents with symptoms from significant outflow tract gradients 50 mm Hg or higher, even with medical therapy. Surgical myectomy can provide low death rates during surgery and excellent results. An alternative, used for older patients and those at high surgical risk, is percutaneous catheter alcohol septal ablation. Any drug that reduces preload decreases the size of the heart chambers and makes the signs and symptoms worse. These drugs include diuretics, nitrates, ACE inhibitors, and ARBs. Vasodilators also worsen ventricular diastolic function by increasing the outflow tract gradient, resulting in reflex tachycardia. The inotropic drugs worsen outflow tract obstruction. They do not relieve high end-diastolic pressure and can cause arrhythmias. These drugs include catecholamines and digitalis glycosides. A newer drug that may be beneficial is mavacamtem, an oral cardiac myosin inhibitor. The drug also reduces LV outflow tract obstruction and increases exercise tolerance.
The Role of Cardiac Magnetic Resonance in Hypertrophic Cardiomyopathy
Published in Srilakshmi M. Adhyapak, V. Rao Parachuri, Hypertrophic Cardiomyopathy, 2020
Gulhane Avanti, Lakhani Zeeshan, Raj Vimal
Surgical myectomy (the Morrow procedure) is indicated in patients with an LVOT gradient ≥ 50 mm Hg, moderate-to-severe symptoms, and/or recurrent exertional syncope in spite of maximally tolerated drug therapy [28]. Specific abnormalities of the mitral valve and its support apparatus, identified on CMR, contributing to outflow tract obstruction, can help in adapting additional surgical approaches, such as plication, valvuloplasty, and papillary muscle relocation, and making myectomy more appropriate than alcohol septal ablation in some patients [28]. When there is a coexisting mid-cavity obstruction, the standard myectomy can be extended distally into the mid-ventricle around the base of the papillary muscles [45]. Selective injection of alcohol into a septal perforator artery (or sometimes other branches of the left anterior descending coronary artery) to create a localized septal scar has outcomes similar to surgery in terms of gradient reduction [46]. Cardiac magnetic resonance is extensively used to assess the effectiveness of alcohol septal ablation in terms of quantification of the amount of tissue necrosis induced, as well as the location of scarring and the regression of the LV mass following the procedure. Septal ablation may be less effective in patients with extensive septal scarring on CMR and in patients with very severe hypertrophy (≥ 30 mm) [47].
Cardiac implantable electrical devices in patients with hypertrophic cardiomyopathy: single center implant data extracted from the Swedish pacemaker and ICD registry
Published in Scandinavian Cardiovascular Journal, 2020
Cinzia Valzania, Fredrik Gadler, Giuseppe Boriani, Claudio Rapezzi, Maria J. Eriksson
The mean age of HCM patients implanted with an ICD was 53 ± 15 years. As shown in Figure 2, most ICD implants were performed in patients aged 50–59 (n = 26) and 60–69 years (n = 26). Most patients were males (70%). Sixty-five (66%) patients were implanted for primary prevention of SCD. Among the patients receiving ICD therapy for secondary prevention (34%), sustained ventricular tachycardia was the most frequent arrhythmia (41%), followed by non-sustained ventricular tachycardia (26%), ventricular fibrillation (21%), and ventricular tachycardia plus ventricular fibrillation (12%). Most frequent clinical manifestations were syncope (24%), breathlessness/tiredness (19%), palpitations (10%), and heart failure (6%). Aborted SCD had been reported in 10% of patients undergoing ICD implant. Twenty-three (23%) ICD patients had paroxysmal/chronic atrial fibrillation. Atrioventricular conduction disorders and sick sinus syndrome had been diagnosed in 11 and 4% of ICD recipients, respectively. As shown in Figure 3, dual-chamber ICDs with or without CRT were implanted in 21 and 65% of the patients, respectively, whereas single-chamber ICDs accounted for 14% of the implants. One patient received first an ICD and was then upgraded to CRT-D. No perioperative complications were observed. Alcohol septal ablation was performed in 16 (16%) ICD patients distributed over years 2003–2016 with start in April 2003. In 15 (94%) cases, ICD implant occurred after alcohol septal ablation.
Long-term outcome of conservative and invasive treatment in patients with hypertrophic obstructive cardiomyopathy
Published in Acta Cardiologica, 2019
Sarah Hoedemakers, Bert Vandenberk, Max Liebregts, Tijs Bringmans, Pieter Vriesendorp, Rik Willems, Johan Van Cleemput
With appropriate treatment in specialised centres, long-term prognosis of HOCM has shown to be similar to that of the general population [8]. The treating physician has the choice between pharmacological or invasive treatment. Usually treatment is initially based on pharmacological treatment with non-vasodilating β-blockers or verapamil. When symptoms persist despite maximum tolerated doses, invasive treatment options need to be considered. Invasive septal reduction therapy can be performed percutaneously by injection of alcohol into a septal branch, alcohol septal ablation (ASA) induces controlled myocardial necrosis and subsequent shrinking of the septal mass. An alternative is septal myectomy, where part of the hypertrophied septum is surgically removed. The objective of this study was to compare long-term outcome of the current treatment options for HOCM in a large tertiary referral university hospital.
Interventional Cardiology at a Pivot Point
Published in Structural Heart, 2018
The area that is currently most investigational but for which interventional procedures may increase the most in the future is the treatment of heart failure. As more and more patients survive cardiac conditions that would have been fatal in the past, the number who ultimately develop heart failure increases. A variety of innovative procedures for heart failure are in early stages of development and evaluation. Several devices have been developed to achieve left atrial decompression in heart failure patients by creating left atrial to right atrial communications analogous to an interatrial septal defect.20,21 The concept is that left atrial pressure and pulmonary congestion can be decreased without adversely impacting cardiac output, right ventricular function, or pulmonary artery pressure. Such an approach might be of particular value in patients with heart failure with preserved ejection fraction. Small early studies have been mildly encouraging. A variety of ventricular partition devices have also been created to treat patients with advanced, generally ischemic left ventricular dysfunction. Percutaneous therapy for these patients, who are high risk for cardiac surgery, would be especially valuable. Catheter procedures are also being employed more frequently to insert left ventricular support devices for cardiogenic shock and in guiding alcohol septal ablation for hypertrophic cardiomyopathy. It is almost certain that, as the number of patients afflicted with advanced heart failure increases, innovative catheter therapeutic procedures for such patients will continue to appear.