Fixed, high‐volume alcohol dose for septal ablation: High risk with no benefit

Abstract

Expert Article Analysis for:Outcomes of hypertrophic obstructive cardiomyopathy patients undergoing alcohol septal ablation with a standard 3 mL dose of ethanol: Focus on long-term safety Fixed, high-volume alcohol dose for septal ablation: High risk with no benefit Key Points• Alcohol volume is positively correlated with mortality following alcohol septal ablation (ASA).• Over time, there has been a trend to use lower volumes of alcohol for ASA. Most cases can and should be performed using 1-2 cc of alcohol.• The volume of alcohol utilized during septal ablation should be determined by anatomic and clinical features of the individual patient.Alcohol septal ablation (ASA) is a well-described therapy for highly symptomatic obstructive hypertrophic cardiomyopathy (HOCM) patients who are refractory to medical therapy. Current guidelines recommend ASA for older patients and those with comorbidities that would engender higher risk for surgical myectomy. 1 This approach offers low procedural mortality and complications, substantial symptomatic improvement, with long-term mortality similar to age and gender-matched populations. 2 A surfeit of data has documented that postprocedural mortality is linearly correlated with the volume of alcohol administered during ASA. 3,4 Consequently, high-volume ASA centers, most usually as part of multidisciplinary HOCM programs, have, over time, migrated to lower and lower alcohol volumes during ASA. 2,3 In this issue of Catheterization and Cardiovascular Interventions, Kashtanov and colleagues describe results in their patients undergoing ASA over a median of approximately 6 years. 5 They used a fixed dose of 3 ml of alcohol in each of their ASA cases, regardless of individual patient anatomy and reported permanent pacemaker (PPM) implantation in 16% of their population, relief of obstruction in approximately 75% with almost 20% of patients requiring repeat intervention forrelief of obstruction, and rates of long-term survival similar to that of age and gender-matched Russian population. Although the approach of a fixed 3 ml dose of alcohol is intriguing in its simplicity, there are substantial limitations to such a strategy that limit its utility.The authors implemented a fixed 3 ml of alcohol dose on the basis of experience with "the first few patients" in their center. Unfortunately, this ignores prior and subsequent data correlating high alcohol doses with mortality while procedural efficacy and salutary outcomes have been documented with migration to much lower doses of alcohol-often one-third that which the authors have employed. In fact, recent European and American data have reported mean alcohol doses of 1-2 ml/case. [2][3][4] Moreover, the larger point is ASA, which is recommended for the relatively small proportion of HOCM patients with dynamic LVOT obstruction, who are highly symptomatic (NYHA Class III-IV) and refractory to medical therapy.The majority of patients currently reported on were at baseline, minimally symptomatic (more than half the population were NYHA Class ...

Alcohol dose in septal ablation for hypertrophic obstructive cardiomyopathy

“…This finding is in line with results of previous studies that demonstrated a positive correlation between alcohol dose and subsequent myocardial biomarker release indicative of the amount of myocardial necrosis [11,26,27]. Thus, from the clinical point of view, an effort to minimize the final post-ASA myocardial scar by using lower doses of alcohol might lead to insufficient tissue ablation and increased need of repeated ASA or myectomy [3,11,28]. Conversely, a more aggressive approach might reduce repeated procedures.…”