Alcohol septal ablation for hypertrophic obstructive cardiomyopathy: Lower alcohol dose reduces size of infarction and has comparable hemodynamic and clinical outcome

Abstract

Patients with highly symptomatic hypertrophic obstructive cardiomyopathy (HOCM) are considered to be good candidates for percutaneous transluminal septal myocardial ablation (PTSMA). However, there is ongoing discussion regarding the optimal dose of alcohol injected into target septal artery and the impact of infarct sizes on the clinical and hemodynamic outcome. Thirty-four patients with symptomatic HOCM receiving maximum medical therapy were consecutively enrolled. Patients were randomized in a 1:1 ratio into one of the two arms according to dose of injected alcohol during echocardiography-guided PTSMA procedure. Clinical, electrocardiographic, and echocardiographic evaluation were performed 6 months after the procedure in all the patients. Both groups of patients matched in all clinical and echocardiographic data. The dose of alcohol injected was 1.6 +/- 0.4 and 3.4 +/- 0.9 (P< 0.001) with subsequent peak of CK-MB 1.9 and 3.2 microkat/L (P < 0.05) in group A and B, respectively. There was a correlation between amount of injected alcohol and the peak of CK-MB (r = 0.58; P < 0.01), whereas no significant relationship (r = 0.16; P = NS) was documented between the peak of CK-MB and left ventricular outflow gradient at follow-up. At 6-month follow-up, both groups of patients were not significantly different with regard to symptoms or electrocardiographic and echocardiographic findings. In conclusion, this study suggests that the low dose (1- 2 ml) of alcohol injected into target septal branch reduces size of necrosis. Moreover, the low dose is probably as safe and efficacious as usually used doses (2-4 ml).

Age-Related Hemodynamic and Morphologic Differences in Patients Undergoing Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy

“…[16][17][18][19] In brief, the presence or absence of significant epicardial coronary artery disease was documented by coronary angiography. A temporary pacemaker was placed in all patients except those who already had a permanent pacemaker or implantable cardioverter difibrillator.…”

“…4 The hemodynamic and clinical benefits of ASA have been clearly demonstrated in many studies to date. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] Reduction of the gradient of the left ventricular outflow tract (LVOT) is biphasic and significant during the early post procedural period; 16,20 however, our clinical experience has suggested that the hemodynamic benefit is less distinct in a subgroup of younger patients. Thus, the aim of our retrospective study was to compare the time course of both hemodynamic and morphological changes with regard to the age of the treated patients.…”

Microvascular Permeability Changes Might Explain Cardiac Tamponade after Alcohol Septal Ablation for Hypertrophic Cardiomyopathy

“…First, to decrease the area of necrosis and the number of damaged microvessels, a smaller volume of ethanol might be injected, thus evoking less pericardial effusion and diminishing the possibility of tamponade. 11,12 Ultralow-dose ethanol (1 mL) has evoked an effect similar to that of higher-dose ethanol (>2 mL). 12 Second, other embolic material, such as glue (cyanoacrylate), might be used to ablate the occluded first septal branch.…”

Non-surgical septal reduction by coil embolization in patients with hypertrophic obstructive cardiomyopathy. An alternative to alcohol ablation

“…The risk of transient or permanent conduction abnormalities after alcohol septal ablation is related to the volume and localization of the myocardium supplied by the occluded artery as well as by the amount of alcohol injected into the septal branch [28][29][30][31][32]. There is a positive correlation between extent of the necrosis caused by ASA and the frequency of conduction abnormalities during and after the procedure [33].…”

“…Despite the use of lower amounts of alcohol (1.5-2 ml) and its slower injection into the artery with prolonged 10 min inflation of the balloon occluding the septal branch, which reduced the ASA complications, especially those related to conduction abnormalities, there is still a group of patients qualified for ASA in whom the risk of described complications is higher and may be a contraindication for this procedure [28,[30][31][32]. This group includes patients with atrioventricular conduction abnormalities present before the procedure or with a large septal branch penetrating to the lower parts of the interventricular septum or covering the whole thickness of the myocardium [34].…”