Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy

Kardiologische Klinik, Herz- und Diabeteszentrum NRW, Universitätsklinik der Ruhr-Universität Bochum, Georgstr. 11, 32545 Bad Oeynhausen, Germany.
Cardiology in Review (Impact Factor: 2.41). 11/1999; 7(6):316-23. DOI: 10.1097/00045415-199911000-00009
Source: PubMed


Until the early 1990s, surgical myectomy was the standard treatment for patients with hypertrophic obstructive cardiomyopathy and drug refractory symptoms. In the past few years, the potential therapeutic options have dramatically changed with the introduction of DDD-pacemaker implantation and percutaneous transluminal septal myocardial ablation by alcohol-induced septal branch occlusion. The circumscribed therapeutic myocardial infarction results in widening of the left ventricular outflow tract with consecutive gradient reduction. Follow-up studies show impressive clinical improvement, as well as further gradient reduction as a result of left ventricular remodeling. In this article, we provide an updated review of the latest results of percutaneous transluminal septal myocardial ablation.

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Available from: Hubert Seggewiss,
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    ABSTRACT: Percutaneous septal ablation has evolved as an alternative to surgery for reducing symptoms and outflow gradients in patients with hypertrophic obstructive cardiomyopathy. Intraprocedural echo-cardiographic imaging can improve clinical and hemodynamic results. Growing experience with this method has additionally shown that threatening necrosis of the myocardium distant from the septal target region can be detected. Percutaneous septal ablation was performed in 162 patients (80 women, 82 men; aged 54.1 +/- 15.5 years); 131 of whom were targeted by intraprocedural myocardial contrast echocardiography. In 11 patients (7%), an atypical target vessel or a perfusion area distant from the expected septal target region was detected, leading to a target vessel change. Permanent pacing was necessary in 14 patients (9%). Three patients (2%) died. After 3 months, the mean New York Heart Association functional class was reduced in the returning 159 patients from 2.8 +/- 0.5 to 1.3 +/- 1.0 (P <.0001) along with a gradient reduction from 77 +/- 35 to 12 +/- 22 mm Hg at rest, and from 147 +/- 43 to 44 +/- 45 mm Hg with provocation (P < .0001 each). The main reason for unsatisfactory gradient reduction was suboptimal scar placement in the patients treated before the introduction of intraprocedural myocardial contrast echocardiography. Percutaneous septal ablation is an effective nonsurgical technique for reducing symptoms and outflow gradients in hypertrophic obstructive cardio-myopathy. Echocardiographic guidance adds substantially to safety and efficacy of the procedure and should therefore be considered routinely.
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    ABSTRACT: Surgery has been the only therapeutic option in patients with hypertrophic obstructive cardiomyopathy (HOCM) who are resistant to standard treatment. Percutaneous transluminal septal myocardial ablation (PTSMA) by alcohol-induced occlusion of the septal artery for the reduction of left ventricular outflow tract (LVOT) gradient is a novel method. However, long-term clinical follow-up is insufficient. This study reports the acute and mid-term results after PTSMA in symptomatic patients with HOCM. Six patients (4 men and 2 women) with symptomatic HOCM and inadequate response to pharmacologic therapy had their major septal branches ablated with alcohol. Mean duration of follow-up was 1.5 years. There was reduction in LVOT gradient in all patients (100%) with a mean reduction of 50 mmHg. Two patients developed complete heart block (CHB) and 3 patients developed bifascicular block. CHB persisted in 1 patient. Two patients died within 8 days of the procedure; one due to cerebrovascular accident and 1 due to asystole. The patient who died of asystole had CHB but refused permanent pacemaker implantation. CHB reverted in 1 patient and bifascicular blocks persisted in 3 patients. Clinical and echocardiographic follow-up was achieved in the 4 surviving patients after 1.5 years. All surviving patients had LVOT gradient reduction and clinical improvement. PTSMA for HOCM is a non-surgical technique for reducing LVOT gradient. Heart blocks are one potential complication, and may require pacemaker implantation. Long-term follow-up and a larger series of patients are required to determine conclusive therapeutic significance.
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    ABSTRACT: Recently, percutaneous transluminal septal myocardial ablation (PTSMA) has been introduced as treatment for symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). We describe our first experience in 24 patients who were treated in our institution during the year 2000. The procedure was initially successful in all but one patient. In that patient the septal branch that was perfusing the proximal septum could not be found. The procedure was complicated in three patients. One patient died suddenly on the second day after the procedure. Two additional patients needed a permanent pacemaker for persisting total heart block. In the other 22 patients the procedure was successful with an acute decrease of the mean outflow tract gradient from 89±43 mmHg to 21±19 mmHg. In those 19 patients who had a follow-up of at least three months (mean follow-up 172±87 days), the mean NYHA class decreased from 2.7±0.7 before PTSMA to 0.6±0.9 at the last follow-up. The echocardiographic gradient decreased from 92±39 mmHg before the procedure to 26±23 mmHg at the last follow-up. Our preliminary results demonstrate that PTSMA is an effective treatment for symptomatic patients with HOCM.
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