Alcohol septal ablation in patients with severe septal hypertrophy

Abstract

ObjectiveThe current guidelines suggest alcohol septal ablation (ASA) is less effective in hypertrophic obstructive cardiomyopathy (HOCM) patients with severe left ventricular hypertrophy, despite acknowledging that systematic data are lacking. Therefore, we analysed patients in the Euro-ASA registry to test this statement.MethodsWe compared the short-term and long-term outcomes of patients with basal interventricular septum (IVS) thickness <30 mm Hg to those with ≥30 mm Hg treated using ASA in nine European centres.ResultsA total of 1519 patients (57±14 years, 49% women) with symptomatic HOCM were treated, including 67 (4.4%) patients with IVS thickness ≥30 mm. The occurrence of short-term major adverse events were similar in both groups. The mean follow-up was 5.4±4.3 years and 5.1±4.1 years, and the all-cause mortality rate was 2.57 and 2.94 deaths per 100 person-years of follow-up in the IVS <30 mm group and the IVS ≥30 mm group (p=0.047), respectively. There were no differences in dyspnoea (New York Heart Association class III/IV 12% vs 16%), residual left ventricular outflow tract gradient (16±20 vs 16±16 mm Hg) and repeated septal reduction procedures (12% vs 18%) in the IVS <30 mm group and IVS ≥30 mm group, respectively (p=NS for all).ConclusionsThe short-term results and the long-term relief of dyspnoea, residual left ventricular outflow obstruction and occurrence of repeated septal reduction procedures in patients with basal IVS ≥30 mm is similar to those with IVS <30mm. However, long-term all-cause and cardiac mortality rates are worse in the ≥30 mm group.

Targeting Alcohol Septal Ablation in Patients with Obstructive Hypertrophic Cardiomyopathy Candidates for Surgical Myectomy: Added Value of Three-Dimensional Intracoronary Myocardial Contrast Echocardiography

“…In particular, in clinical practice ASA is preferred to SM mainly in the elderly at high operative SM risk, who may have a different septal phenotype from non-elderly HCM patients at low operative SM risk. Indeed, non-elderly HCM patients at low SM risk may have a high-penetrance phenotype that is substantially different from age-dependent remodeled septal phenotype [ 8 , 10 , 70 , 71 , 72 , 73 ]. Thus, in the general population of HCM patients, the prevalence of ASA feasibility may differ.…”

Hypertrophic Cardiomyopathy: Genetics, Pathogenesis, Diagnosis, Clinical Course and Therapy

“…Surgical myectomy has demonstrated excellent long-term efficacy and safety at selected high-volume centres with near-complete resolution of resting and inducible LVOT gradients. ASA showed similar perioperative mortality (about 1%) when compared to myectomy [136], although associated with a 10-15% rate of complete heart block, repeat procedures and increased risk of scar-related ventricular arrhythmias [137,138]. Moreover, ASA is dependent on coronary anatomy since 15% of patients had unsuitable septal perforators [139].…”

Ten Tips and Tricks for Performing Alcohol Septal Ablation in Patients with Hypertrophic Obstructive Cardiomyopathy

“…It has been recently demonstrated that in selected patients, with both the modest septum thickness (15-16 mm) and with severe septal hypertrophy, ASA was found effective and safe in the long-term follow-up. 1,7 LVOT obstruction depends largely on the length of mitral leaflets and submitral chords, papillary muscle abnormalities including their number, hypertrophy, localization, and possible direct attachment to anterior mitral leaflet or short interposition of chords. Evidence suggests some patients encounter obstruction not only in LVOT but also in the midventricular part, therefore the precise evaluation of obstruction is necessary, and adding magnetic resonance imaging or computer tomography of a heart is very valuable.…”

“…ASA is described as an interventional procedure guided by myocardial contrast echocardiography and the first septal branch is considered as the usual target of alcohol injection. 1,[4][5][6][7][8] The morphological result of ASA should be similar to myectomy which is difficult to achieve in all patients because of anatomical variations of septal branches. A preprocedural computerized tomography coronary angiography could benefit in identifying the optimal septal (sub)branch.…”

“…Improvement of patients' symptoms after ASA is expected in 90% of the patients, with a mean reduction of LVOT pressure gradient of 75% and final New York Heart Association (NYHA) class reduction of approximately 1.5. 1,[4][5][6][7][8] The immediate post-ASA reduction of LVOT obstruction, caused by necrosis and a subsequent stunning of the heart, is followed by a transient pressure gradient increase in the first post-ASA week, and is later followed by a gradual LVOT obstruction reduction/elimination in the following months. 12,13 This reduction is caused by shrinking of the ablated septum.…”