Ventricular Arrhythmia Following Alcohol Septal Ablation for Obstructive Hypertrophic Cardiomyopathy

Noseworthy, Peter A.; Rosenberg, Michael; Fifer, Michael A.; Palacios, Igor F.; Lowry, Patricia A.; Ruskin, Jeremy N.; Sanborn, Danita M. Yoerger; Picard, Michael H.; Vlahakes, Gus J.; Mela, Theofanie; Das, Saumya

doi:10.1016/j.amjcard.2009.02.056

Cited by 88 publications

(55 citation statements)

References 16 publications

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“…Results from multicenter studies and metaanalyses comparing incidence of ventricular tachycardia and fibrillation in large cohorts of patients after alcohol septal ablation vs. surgical myectomy remain open to contrasting interpretations (37,38). One limitation of such investigations is the shorter period of follow-up and incompleteness of data on appropriate ICD interventions in septal ablation cohorts compared to long-term surgical series (37).…”

Section: Arrhythmogenic Potential Of Alcohol Septal Ablationmentioning

confidence: 99%

“…Nevertheless, in a recent multicenter European study, appropriate ICD shocks for ventricular tachycardia or fibrillation were 8-fold more common after septal ablation than surgical myectomy (13). Furthermore, major HCM centers have reported a higher rate of ventricular tachyarrhythmias, cardiac arrest, or appropriate ICD interventions after alcohol septal ablation (12,38), and some centers have prophylactically implanted ICDs for primary prevention after septal ablation (22). In contrast to these recurring concerns regarding arrhythmic risk associated with alcohol septal ablation, available data show that surgical myectomy extends survival with an exceedingly low rate of events, including ventricular tachyarrhythmias and sudden death, during long-term follow-up (5,7,10).…”

Section: Arrhythmogenic Potential Of Alcohol Septal Ablationmentioning

confidence: 99%

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Alcohol septal ablation: in which patients and why?

Spirito¹,

Rossi²,

Maron³

2017

Ann. Cardiothorac. Surg.

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At present, surgical septal myectomy is regarded as the "gold standard" treatment for most patients with obstructive hypertrophic cardiomyopathy (HCM) and drug-refractory symptoms. However, the best results are obtained by those surgeons who have extensive experience with this operation at a small number of referral centers. In the mid-1990s, percutaneous alcohol septal ablation was introduced as an alternative to myectomy to reduce LV outflow gradient and heart failure symptoms in patients with obstructive HCM. However, certain features of alcohol ablation limit its applicability to carefully selected patients.Because this procedure involves the injection of 1-4 mL of 96% ethanol into a septal perforator of the left anterior coronary artery to produce a myocardial infarction (with septal thinning, outflow tract widening and gradient reduction), alcohol ablation is limited by the size and distribution of the septal perforator branches. In addition, rich blood supply from other septal branches not occluded by the balloon and from the posterior descending coronary artery may restrict myocardial ischemia to portions of the septum that do not contribute to outflow obstruction. Septal hypertrophy may be either mild or particularly marked, and abnormalities of mitral valve apparatus may also play a major role in outflow obstruction. When such features are present, alcohol-induced septal thinning is unlikely to significantly reduce the gradient. In addition, persisting uncertainties regarding the risk for ventricular tachyarrhythmias after alcohol ablation suggest this procedure should be limited to patients of advanced age, patients at unacceptable operative risk due to comorbidities, or those with strong aversion to surgery. Further progress in the treatment for patients with obstructive HCM and severe refractory symptoms will come from assuring proper patient selection for alcohol septal ablation, as well as increasing the number of surgeons and centers experienced in performing septal myectomy. PerspectiveIn patients with hypertrophic cardiomyopathy (HCM), left ventricular (LV) outflow obstruction with a pressure gradient between the LV outflow tract and aorta is caused by systolic anterior motion of the mitral valve against the septum (1), and is identified at rest or with physiologic exercise in about 70% of patients evaluated at tertiary referral centers (2). Obstruction to LV outflow obstruction is associated with mitral valve regurgitation, disabling heart failure symptoms and increased cardiovascular mortality (3,4). For almost 50 years, transaortic septal myectomy has represented the standard surgical approach for the treatment of patients with obstructive HCM and severe symptoms refractory to medical treatment (1,5-7).In the mid-1990s, percutaneous alcohol septal ablation was introduced as an alternative to surgical myectomy to reduce the LV outflow gradient and heart failure symptoms in patients with obstructive HCM (8). This catheterbased procedure, made attractive by its less invasive nature, was rapidl...

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Section: Arrhythmogenic Potential Of Alcohol Septal Ablationmentioning

confidence: 99%

Section: Arrhythmogenic Potential Of Alcohol Septal Ablationmentioning

confidence: 99%

Alcohol septal ablation: in which patients and why?

Spirito¹,

Rossi²,

Maron³

2017

Ann. Cardiothorac. Surg.

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“…A perceived increased risk secondary to the fibrotic scar left behind after ASA may justify the extensive use of cardioverter-defibrillators (ICDs) following this approach (41). There have been numerous reports pointing to potential increased risk of sudden death or need for ICD discharges following ASA (42)(43)(44)(45). Conversely, myectomy does not add any extra risk (1).…”

Section: Arrhythmia Following Asamentioning

confidence: 99%

Septal myectomy after failed septal alcohol ablation

Bajona

Arguís

Prat‐González

2017

Ann. Cardiothorac. Surg.

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Despite septal myectomy remaining the gold standard septal reduction therapy for hypertrophic obstructive cardiomyopathy (HOCM), there has been a disproportionate use of alcohol septal ablation (ASA) worldwide.Absolute resolution of left ventricular outflow tract (LVOT) obstruction with ASA is not achieved in a substantial proportion of patients. The mechanisms of failure from ASA are partially understood and described. Residual obstruction in hypertrophic cardiomyopathy is associated with worse clinical outcomes and mortality. There is a growing number of patients who present with significant residual gradients after ASA and require a rescue septal myectomy operation, which then carries an increased risk of perioperative complications and life-long sequelae. This contrasts with the excellent outcomes achieved by septal myectomy without previous percutaneous intervention. Despite complete resolution of obstruction in rescue myectomy, the outcomes remain compromised by the prior ASA.

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“…87, 88 In fact, it seems that a less successful hemodynamic outcome may be associated with a higher arrhythmic risk, with the risk of arrhythmia increasing as the post-interventional gradient increases. 89 The advent of myocardial contrast echocardiography during percutaneous septal ablation has been shown to improve the hemodynamic result and decrease the complication risk. 31, 73 Use of the proper contrast agent enables better imaging quality, thus ensuring the safety of the procedure, which could be also applied to treat patients with midventricular obstruction or who had undergone a previously unsuccessful surgical attempt.…”

Section: Complicationsmentioning

confidence: 99%

A Decade of Percutaneous Septal Ablation in Hypertrophic Cardiomyopathy

Rigopoulos

Seggewiß

2011

Circ J

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Percutaneous septal ablation has emerged as a less invasive treatment of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). In the past decade, the availability of this sophisticated technique has revived the interest of cardiologists in left ventricular outflow tract obstruction, which led to the recognition that most patients with HCM have the obstructive type. Follow-up studies have already shown the safety and efficacy of the procedure, which offers symptomatic relief in most patients. Long-term survival is comparable to historical reports after surgical myectomy. Complications are rare and can be further reduced with increased experience of the operators, and the theoretical concern for possible ventricular arrhythmogenicity of the myocardial scar has not been documented by the existing data. Although there are still no randomized trials, percutaneous septal ablation is undeniably a viable alternative for patients with HOCM. (Circ J 2011; 75: 28 - 37)

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Ventricular Arrhythmia Following Alcohol Septal Ablation for Obstructive Hypertrophic Cardiomyopathy

Cited by 88 publications

References 16 publications

Alcohol septal ablation: in which patients and why?

Alcohol septal ablation: in which patients and why?

Septal myectomy after failed septal alcohol ablation

A Decade of Percutaneous Septal Ablation in Hypertrophic Cardiomyopathy

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