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Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy. John F. Robb, MD Associate Professor of Medicine Director, Cardiac Catheterization Laboratories. December 6, 2004. Alcohol Septal Ablation. Case Presentation The patient is a 61 year old female History of lifelong murmur

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alcohol septal ablation in hypertrophic obstructive cardiomyopathy

Alcohol Septal AblationinHypertrophic Obstructive Cardiomyopathy

John F. Robb, MD

Associate Professor of Medicine

Director, Cardiac Catheterization Laboratories

December 6, 2004

alcohol septal ablation
Alcohol Septal Ablation

Case Presentation

  • The patient is a 61 year old female
  • History of lifelong murmur
  • Followed for about 10 years with echocardiography for hypertrophic obstructive cardiomyopathy
  • 9 months of increasing dyspnea on exertion:
    • NYHA Class III, < 1 flight, <1 block
    • No orthopnea, PND, or edema
  • CCS class III exertional angina
    • Humid weather = “big elephant”
    • Dry weather = “small elephant”
  • Frequent lightheadedness, one episode of syncope 30 years ago
alcohol septal ablation3
Alcohol Septal Ablation

Case Presentation

  • Treated with calcium blockers for 8 years, but never tried on beta blockers or disopyramide.
  • Trial of beta blockers resulted in worsened dyspnea on exertion and dizziness, with episodes of pre-syncope
alcohol septal ablation4
Alcohol Septal Ablation

Case Presentation

  • Past Medical History:
    • Asthma
    • Hypothyroidism
    • Hepatic angioma
    • Elevated cholesterol
    • s/p strabismus surgery yrs ago
  • Social History:
    • Tax preparer, married mother of 4 children
    • Non-smoker
alcohol septal ablation5
Alcohol Septal Ablation

Case Presentation

  • Work up at another institution included
    • Echocardiography showing diffuse LV hypertrophy with asymmetric septal thickening and a resting ~ 64 mmHg gradient across the LVOT which increased to > 100 mmHg with Valsalva maneuver
    • Cardiac catheterization LVEF 84% 50 mmHg resting LVOT gradient, LV Systolic pressure increased from 140 mmHg to 260 mmHg with Valsalva and post PVC. Coronary arteries were normal. There was + 2-3 mitral regurgitation.
alcohol septal ablation6
Alcohol Septal Ablation

Case Presentation

  • Surgical mitral valve replacement and septal myomectomy was recommended with a quoted 3-5% operative mortality.
  • Patient and her husband sought a second opinion.
alcohol septal ablation7
Alcohol Septal Ablation

Case Presentation

  • Physical Exam:
    • BP-140/70, P-80, R-12
    • Chest clear
    • Cor- 2/6 systolic ejection murmur left sternal border which increases in intensity and duration with Valsalva, +S4
    • Abdomen obese without organomegaly
    • Trace edema
slide8

Alcohol Septal Ablation

Case Presentation

  • EKG:
alcohol septal ablation9
Alcohol Septal Ablation

Case Presentation

  • Echocardiogram
    • Moderate concentric LVH
    • Asymmetric septal hypertrophy, 2 cm
    • Systolic anterior motion of the mitral valve
    • Dynamic LVOT gradient ~ 100 mmHg at rest
    • +2/+4 mitral regurgitation
    • LVEF 75% without regional wall motion abnormalities
    • Estimated RV systolic pressure 41 mmHg
slide22

Alcohol Septal Ablation

Case Presentation

  • Temporary pacer
  • 2 cc absolute ETOH administered
  • Mild chest pain
  • Occlusion of the 1st septal on follow-up angiography
  • Transient complete heart block, resolved in 10 minute
  • Procedural Echo:
    • LVOT gradient was reduced from 84 to 14 mmHg
    • SAM resolved, LVEF 75%, 1-2+ MR
  • CK rose to 1339, Troponin T to 3.86
  • No arrhythmias noted on telemetry
  • Discharged to home at post procedure day 3
alcohol septal ablation23
Alcohol Septal Ablation

Case Presentation

  • Post EKG
slide24

Alcohol Septal Ablation

Case Presentation

Follow-up 30 days:

  • Dyspnea and angina resolved, Class 0
  • No dizziness or syncope
  • Calcium blocker continued for hypertension
  • Echo 30 days:
    • No resting LVOT gradient
    • 95 mmHg LVOT gradient with Valsalva
    • 1-2+ MR
    • LVEF 75%
alcohol septal ablation27
Alcohol Septal Ablation

Case Presentation

  • 30 day EKG:
alcohol septal ablation28
Alcohol Septal Ablation

Case Presentation

Follow-up 180 days:

No angina, dyspnea, dizziness or syncope

Fully active without symptoms

“Feels great!”

Calcium Channel blocker weaned

alcohol septal ablation echo 180 days post29
Alcohol Septal AblationEcho 180 days post
  • Echo 180 days
    • Moderate LVH
    • No LVOT gradient at rest or with Valsalva
    • 1-2+ MR
    • LVEF 75%
    • RV systolic pressure 30 mmHg
alcohol septal ablation outcomes
Alcohol Septal AblationOutcomes
  • 213 consecutive symptomatic patients
  • Followed for 4 years
  • 97% procedures successful
  • 1% repeat procedures
  • 15% permanent pacers
  • Mortality
    • Overall 4%
    • Procedural 1%
    • Sudden death 1%
    • Non-cardiac 2%
  • Better outcome if:
    • LVOT gradient < 25 mmHg at time of procedure
    • CK ≥ 1300

Spencer, JACC 2002

Spencer, Circulation 2004 109:824

alcohol septal ablation34
Alcohol Septal Ablation

Surgical Myomectomy

  • 1-5% mortality
  • Morbidity of median sternotomy, cardiopulmonary bypass
  • Few expert centers
  • 10-20% mortality in elderly

A-V Pacing

  • Blinded crossover studies: no significant long term symptom relief
alcohol septal ablation therapy
Alcohol Septal AblationTherapy

Holmes, NEJM 2004 350:1320

alcohol septal ablation37
Alcohol Septal Ablation

Interventricular septal reduction with alcohol ablation is a useful non- surgical approach to patients with hypertrophic obstructive cardiomyopathy who remain symptomatic despite medical therapy.

alcohol septal ablation hemodynamics pre39
Alcohol Septal AblationHemodynamics Pre

Hemodynamics of HOCM

  • Brisk Ao upstroke, late systolic gradient
  • Brockenbrough Braunwald Morrow sign
    • Increased LVOT gradient following PVC
    • Decreased Ao pulse pressure following PVC
  • Increased LVOT gradient with:
    • Decreased LV end diastolic volume
      • Shortened diastole
      • Decreased LA pressure
    • Increased contractility
    • Decreased aortic impedence
  • Valsalva
  • Nitroglycerin
  • PVC’s
  • Dobutamine or isoproterenol
  • Exercise