Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy: A Systematic Review of Published Studies

Abstract

Literature to date suggests that ASA results in acute and intermediate-term favorable clinical and echocardiographic outcomes. A randomized controlled trial is needed to compare ASA and myomectomy in order to determine which technique provides maximal benefit.

Alcohol septal ablation in obstructive hypertrophic cardiomyopathy: Four years of experience at a reference center

“…15 In 2006, Alam et al published a meta-analysis of 42 studies on outcomes after ASA in 2959 patients. 16 At 12 months, there was a sustained decrease in resting and provoked LVOT gradient (65.3 to 15.8 mmHg and 125.4 to 31.5 mmHg, respectively) accompanied by reduction in basal septal thickness (20.9 to 13.9 mm), improvement in NYHA class (2.9 to 1.2), and increase in exercise capacity (325.3 to 437.5 seconds). ASA is associated with sustained improvements in symptoms and gradient in >85% of patients.…”

“…17,18 Repeat ASA due to persistence or recurrence of symptoms is necessary in around 7% of cases, a similar figure to myectomy. 16 ASA results in increased LVOT area and reduced gradient 19,20 ; besides symptomatic improvement, its benefits include increased coronary flow reserve 21 and LV size and reduced LV mass, 22 end-diastolic pressure, 14 left atrial size 14 and mitral regurgitation. 23 The clinical effects observed are also due to improved LV diastolic function, which is comparable to that obtained by myectomy.…”

“…Alam et al described dissection of the anterior descending artery in 1.8% of patients, 16 while cardiac tamponade caused by insertion of the temporary pacing catheter has a reported incidence of 0.6%. 16 Alcohol leakage to the anterior descending artery or via collaterals to remote tissues is a serious complication that can lead to an unconfined infarction outside the target area. Leakage can be avoided by taking great care to keep the balloon fully inflated and to maintain the stability of the entire system to prevent reflux of alcohol.…”

“…Complete sustained AVB is less frequent with myectomy (5% as opposed to 10% with ASA); this is probably the main difference in the results of the two techniques. 16 ASA has the advantages of other percutaneous treatments: it is less invasive, does not require sternotomy, is associated with shorter recovery time, and can be used to treat patients with relative or absolute contraindications for surgery, such as elderly or obese individuals and those with significant comorbidities. Clinical outcomes are similar to those of myectomy, as shown in two recent meta-analyses, in which the only difference was the need for permanent pacing.…”

How Can we Improve Non-Surgical Septal Reduction for Hypertrophic Obstructive Cardiomyopathy?

“…Indeed, it has been estimated that more ASAs have been performed in the past approximate 10 years than all myomectomies ever performed [9]. With overlapping but different indications, surgical myomectomy on cardiopulmonary bypass pump and the less invasive percutaneous alcoholic ablation through a septal artery provide the only two accepted modalities of therapy for severely symptomatic obstructive HCM, when medications have failed [10,11]. There is a difference of opinion in the scientific community on which approach is better, as well as a debate regarding the feasibility of and need for a randomized trial [12].…”