Intracardiac echocardiography
Debabrata Mukherjee, Eric R. Bates, Marco Roffi, Richard A. Lange, David J. Moliterno, Nadia M. Whitehead in Cardiovascular Catheterization and Intervention, 2017
Alcohol septal ablation is an effective treatment to reduce the intraventricular gradient in patients with hypertrophic obstructive cardiomyopathy.66 However, the efficacy and safety of the procedure is dependent on the identification of the correct septal artery. To identify this branch, echo contrast is commonly injected into a septal artery at the time of coronary angiography, and TTE is used to detect the extent and localization of the corresponding myocardial territory. ICE allows high-quality visualization of the entire interventricular septum and may be a useful tool to guide alcohol septal ablation.67 Recently, it has been demonstrated that the use of image integration of ICE and electroanatomical mapping may facilitate a radiofrequency ablation procedure of the interventricular septum to treat hypertrophic obstructive cardiomyopathy.68 However, more studies are needed to define the role of ICE in alcohol septal ablation or radiofrequency ablation in patients with hypertrophic obstructive cardiomyopathy.
Cardiac Hypertrophy, Heart Failure and Cardiomyopathy
Mary N. Sheppard in 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.
Complications of Septal Myectomy
Srilakshmi M. Adhyapak, V. Rao Parachuri in Hypertrophic Cardiomyopathy, 2020
Complete heart block requiring implantation of a permanent pacemaker is a well-known complication of septal myectomy. The incidence of postoperative pacemaker implantation has been reported as less than 5% in large series of septal myectomy [6, 7, 11]. This compares favorably with alcohol septal ablation, which carries a risk of 10–15% for heart block, requiring implantation of a permanent pacemaker [12], which has significant consequences for the patient undergoing cardiac surgery. The need for a permanent pacemaker after surgical aortic valve replacement (AVR) may reduce long-term survival [13]. Permanent pacemaker implantation in patients undergoing septal myectomy, who are younger on average than those undergoing AVR, may be subject to secondary long-term deleterious effects.
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 therapies for relief of obstruction in hypertrophic cardiomyopathy: discussion and proposed clinical algorithm
Published in Hospital Practice, 2018
Srihari S Naidu, Jason Jacobson, Sei Iwai, Tanya Dutta, Wilbert S Aronow, Angelica Poniros, Ramin Malekan, David Spielvogel, Julio A Panza
Alcohol septal ablation proceeds initially with temporary pacemaker placement, due to the 5–10% incidence of complete heart block that can develop post-procedure. While traditionally these were placed via the femoral vein, our recent experience has modified these to be externalized screw-in active fixation leads via the right internal jugular vein, thereby allowing the device to stay in longer, encourage ambulation while in hospital, and avoid accrued pacemaker complications such as effusion or tamponade. Care must be taken to place the lead at the apical septum, so that it is far removed from any area of septal ablation, which might affect pacemaker capture thresholds. Once the pacemaker is placed, it is set at a low rate, usually 40 beats/min, as back-up pacing. Baseline echo views are then obtained. This includes the parasternal long axis view, and apical 2, 3, 4, and 5 chamber views. The purpose of these views are to determine the level of opacification and wall motion of all relevant walls, including any area ethanol may inadvertently travel to. This includes the mid-septum, moderator band and free wall of the right ventricle, papillary muscles, and the anterior wall, posterior wall and apex of the left ventricle. The 3 and 5 chamber views are utilized to obtain outflow tract gradients.
Pharmacological and non-pharmacological treatment of obstructive hypertrophic cardiomyopathy
Published in Expert Review of Cardiovascular Therapy, 2018
Luis F. Hidalgo, Srihari S. Naidu, Wilbert S. Aronow
The main concern in regards to alcohol septal ablation was the induction of infarct and the formation of scar with subsequent potential substrate for ventricular arrhythmias [24]. Most of the studies comparing alcohol septal ablation to surgical myectomy report a similar event of ventricular arrhythmias except for one [25,26], however, and this latter study was criticized for being of an early era in the iteration of alcohol septal ablation, with average ethanol volume of over 3 cc, and in many cases over 5 cc. More importantly, short-term mortality and long-term mortality have been found to be similar for both procedures by most of the current studies, at least to 8–10 years [25–27]. This includes studies from large primarily surgical centers, where alcohol septal ablation was performed mainly in poor surgical candidates. The lack of mortality difference in such a study, with such a selection bias favoring surgery, is reassuring.
Related Knowledge Centers
- Blood Pressure
- Interventional Cardiology
- Interventricular Septum
- Hypertrophic Cardiomyopathy
- Hypertension
- Ventricle
- Cardiac Muscle
- Pathophysiology
- Minimally Invasive Procedure
- Percutaneous