Alcohol septal ablation

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Alcohol septal ablation
Other namesTASH procedure
Specialty Cardiology

Alcohol septal ablation (ASA) is a minimally invasive heart procedure to treat hypertrophic cardiomyopathy (HCM). [1]

Contents

It is a percutaneous, minimally invasive procedure performed by an interventional cardiologist to relieve symptoms and improve functional status in eligible patients with severely symptomatic HCM who meet strict clinical, anatomic and physiologic selection criteria. In carefully selected patients, when performed by an experienced interventional cardiologist, the procedure is successful in relieving symptoms in over 90% of patients.

Hypertrophic cardiomyopathy is a condition of the cardiac muscle which grows abnormally thick in the absence of a pathophysiologic cause such as hypertension (high blood pressure) or aortic valve disease. In a large subset of patients with hypertrophic obstructive cardiomyopathy, thickening of the heart muscle in a particular part of the interventricular septum causes obstruction to blood being ejected from the left ventricle.

Alcohol septal ablation is a cardiac catheterization technique designed to reduce the obstruction to blood being ejected from the heart. The technique creates a small controlled myocardial infarction, killing the area of heart muscle responsible for the obstruction, and eventually causing it to fibrose and become less thick.

History

Alcohol septal ablation was first performed in 1994 by Ulrich Sigwart at the Royal Brompton Hospital in the United Kingdom. [2] Since that time, it has gained favor among physicians and patients due to its minimally invasive nature, thereby avoiding general anesthesia, lengthy inpatient recuperation and other complications associated with open-heart surgery (e.g. septal myectomy).[ citation needed ]

Technique

Alcohol septal ablation is performed in the cardiac catheterization laboratory, and should only be performed by interventional cardiologists with specific training in the procedure. (Current guidelines suggest at least 20 successful procedures to demonstrate competence.) As such, it is only available in a few institutions. The technique is similar to coronary angioplasty, and utilizes similar equipment. Using wires and balloons to localize the septal artery feeding the diseased muscle under both fluoroscopic (X-ray) and echocardiographic (ultrasound) guidance, a small amount of pure alcohol is infused into the artery to produce a small heart attack. Patients typically experience mild chest discomfort during the procedure, which takes approximately 60–90 minutes to complete. Analgesics and mild sedatives are administered as needed. Patients typically are maintained in the hospital for three to four days to monitor for any complications, including the need for a permanent pacemaker in 5–10%. Complications are reduced in high volume centers, defined as a center that has performed more than 50 procedures, or an operator who has performed more than 20.[ citation needed ]

Outcomes

Relief of obstruction is noted immediately in the majority of appropriately selected patients. Clinical success is defined as a 50% or more reduction in peak gradient across the outflow tract, predicting continued improvement in gradient and cardiac remodeling over the ensuing 1 to 2 years. Over 90% of patients experience a successful procedure, with improvement in outflow tract gradient and mitral regurgitation.[ medical citation needed ] Patients typically report progressive reduction in symptoms, including improved shortness of breath, lightheadedness and chest pain. Serial echocardiograms are routinely obtained to follow the cardiac remodeling over time, and document reduction in outflow tract gradient.[ citation needed ] Although alcohol septal ablation improves symptoms associated with HCM, it does not decrease the risk of sudden cardiac death (SCM) and may possibly increase it due to theoretical risk for arrhythmogenic scarring. [3]

When compared to surgical myectomy, similar outcomes are noted out to approximately 10 years. [4] However, a prospective, randomized trial has not been performed. Despite initial concerns regarding long-term arrhythmic potential after alcohol septal ablation, the risk appears to be no worse than for surgical myectomy. It is important to note that patients who fail to respond to alcohol septal ablation may still be candidates for surgical myectomy, and vice versa. [5] Which patients are best served by surgical myectomy, alcohol septal ablation, or medical therapy is an important topic and one which is intensely debated in medical scientific circles. [6]

Related Research Articles

<span class="mw-page-title-main">Cardiology</span> Branch of medicine dealing with the heart

Cardiology is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease and electrophysiology. Physicians who specialize in this field of medicine are called cardiologists, a specialty of internal medicine. Pediatric cardiologists are pediatricians who specialize in cardiology. Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons, a specialty of general surgery.

<span class="mw-page-title-main">Tetralogy of Fallot</span> Type of congenital heart defect

Tetralogy of Fallot (TOF), formerly known as Steno-Fallot tetralogy, is a congenital heart defect characterized by four specific cardiac defects. Classically, the four defects are:

<span class="mw-page-title-main">Palpitations</span> Perceived cardiac abnormality in which ones heartbeat can be felt

Palpitations are perceived abnormalities of the heartbeat characterized by awareness of cardiac muscle contractions in the chest, which is further characterized by the hard, fast and/or irregular beatings of the heart.

Hypertrophic cardiomyopathy is a condition in which the heart becomes thickened without an obvious cause. The parts of the heart most commonly affected are the interventricular septum and the ventricles. This results in the heart being less able to pump blood effectively and also may cause electrical conduction problems.

<span class="mw-page-title-main">Atrial septal defect</span> Human heart defect present at birth

Atrial septal defect (ASD) is a congenital heart defect in which blood flows between the atria of the heart. Some flow is a normal condition both pre-birth and immediately post-birth via the foramen ovale; however, when this does not naturally close after birth it is referred to as a patent (open) foramen ovale (PFO). It is common in patients with a congenital atrial septal aneurysm (ASA).

<span class="mw-page-title-main">Cardiac catheterization</span> Insertion of a catheter into a chamber or vessel of the heart

Cardiac catheterization is the insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes.

<span class="mw-page-title-main">Ventricular hypertrophy</span> Medical condition

Ventricular hypertrophy (VH) is thickening of the walls of a ventricle of the heart. Although left ventricular hypertrophy (LVH) is more common, right ventricular hypertrophy (RVH), as well as concurrent hypertrophy of both ventricles can also occur.

Pulsus paradoxus, also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus. Pulsus paradoxus is not related to pulse rate or heart rate, and it is not a paradoxical rise in systolic pressure. The normal variation of blood pressure during breathing/respiration is a decline in blood pressure during inhalation and an increase during exhalation. Pulsus paradoxus is a sign that is indicative of several conditions, including cardiac tamponade, chronic sleep apnea, croup, and obstructive lung disease.

<span class="mw-page-title-main">Cardiomegaly</span> Medical condition

Cardiomegaly is a medical condition in which the heart is enlarged. As such, it is more commonly referred to simply as "having an enlarged heart". It is usually the result of underlying conditions that make the heart work harder, such as obesity, heart valve disease, high blood pressure (hypertension), and coronary artery disease. Cardiomyopathy is also associated with cardiomegaly.

<span class="mw-page-title-main">Disopyramide</span> Chemical compound

Disopyramide is an antiarrhythmic medication used in the treatment of ventricular tachycardia. It is a sodium channel blocker and therefore classified as a Class 1a anti-arrhythmic agent. Disopyramide has a negative inotropic effect on the ventricular myocardium, significantly decreasing the contractility. Disopyramide also has an anticholinergic effect on the heart which accounts for many adverse side effects. Disopyramide is available in both oral and intravenous forms, and has a low degree of toxicity.

Septal myectomy is a cardiac surgery treatment for hypertrophic cardiomyopathy (HCM). The open-heart surgery entails removing a portion of the septum that is obstructing the flow of blood from the left ventricle to the aorta.

Alan W. Heldman is an American interventional cardiologist. Heldman graduated from Harvard College, University of Alabama School of Medicine, and completed residency and fellowship training at Johns Hopkins University School of Medicine. He held positions on the faculty of Johns Hopkins from 1995 to 2007. In 2007, he became clinical chief of cardiology at the University of Miami's Leonard M. Miller School of Medicine.

<span class="mw-page-title-main">Atrial septostomy</span> Surgical procedure on the heart

Atrial septostomy is a surgical procedure in which a small hole is created between the upper two chambers of the heart, the atria. This procedure is primarily used to palliate dextro-Transposition of the great arteries or d-TGA, a life-threatening cyanotic congenital heart defect seen in infants. It is performed prior to an arterial switch operation. Atrial septostomy has also seen limited use as a surgical treatment for pulmonary hypertension. The first atrial septostomy was developed by Vivien Thomas in a canine model and performed in humans by Alfred Blalock. The Rashkind balloon procedure, a common atrial septostomy technique, was developed in 1966 by American cardiologist William Rashkind at the Children's Hospital of Philadelphia.

Gerald Murray Lawrie, M.D. is an American heart surgeon and pioneer in the surgical treatment of valvular heart disease of Australian descent.

<span class="mw-page-title-main">Hypertrophic cardiomyopathy screening</span> Procedure for detecting a form of heart disease

Hypertrophic cardiomyopathy screening is an assessment and testing to detect hypertrophic cardiomyopathy (HCM).

Ulrich Sigwart is a retired cardiologist known for his pioneering role in the conception and clinical use of stents to keep blood vessels open, and introducing a non-surgical intervention, alcohol septal ablation for the treatment of hypertrophic obstructive cardiomyopathy.

<span class="mw-page-title-main">Hybrid cardiac surgery</span>

A hybrid cardiac surgical procedure in a narrow sense is defined as a procedure that combines a conventional, more invasive surgical part with an interventional part, using some sort of catheter-based procedure guided by fluoroscopy imaging in a hybrid operating room (OR) without interruption. The hybrid technique has a reduced risk of surgical complications and has shown decreased recovery time. It can be used to treat numerous heart diseases and conditions and with the increasing complexity of each case, the hybrid surgical technique is becoming more common.

Barry A. Love M.D. is a cardiologist specializing in pediatric and congenital heart problems.

Srihari S. Naidu is an American physician and Professor of Medicine at New York Medical College who is known for his work on hypertrophic cardiomyopathy including the procedure known as alcohol septal ablation, and for helping to construct the universal diagnostic criteria for cardiogenic shock.

<span class="mw-page-title-main">Mavacamten</span>

Mavacamten, sold under the brand name Camzyos, is a medication used to treat obstructive hypertrophic cardiomyopathy.

References

  1. ↑ Cui, Hao; Schaff, Hartzell V. (2020). "80. Hypertrophic cardiomyopathy". In Raja, Shahzad G. (ed.). Cardiac Surgery: A Complete Guide. Switzerland: Springer. pp. 735–748. ISBN   978-3-030-24176-6.
  2. ↑ Sigwart U (July 1995). "Non-surgical myocardial reduction for hypertrophic obstructive cardiomyopathy". Lancet. 346 (8969): 211–214. doi:10.1016/S0140-6736(95)91267-3. PMID   7616800. S2CID   32959772.
  3. ↑ Maron, Barry J.; Spirito, Paolo; Shen, Win-Kuang; Haas, Tammy S.; Formisano, Francesco; Link, Mark S.; Epstein, Andrew E.; Almquist, Adrian K.; Daubert, James P.; Lawrenz, Thorsten; Boriani, Giuseppe (2007-07-25). "Implantable Cardioverter-Defibrillators and Prevention of Sudden Cardiac Death in Hypertrophic Cardiomyopathy". JAMA. 298 (4): 405–412. doi:10.1001/jama.298.4.405. ISSN   0098-7484. PMID   17652294.
  4. ↑ Ralph-Edwards A, Woo A, McCrindle BW, et al. (February 2005). "Hypertrophic obstructive cardiomyopathy: comparison of outcomes after myectomy or alcohol ablation adjusted by propensity score". J. Thorac. Cardiovasc. Surg. 129 (2): 351–358. doi: 10.1016/j.jtcvs.2004.08.047 . PMID   15678046.
  5. ↑ Juliano N, Wong SC, Naidu SS (October 2005). "Alcohol septal ablation for failed surgical myectomy". J Invasive Cardiol. 17 (10): 569–571. PMID   16204755.
  6. ↑ Heldman AW, Wu KC, Abraham TP, Cameron DE (January 2007). "Myectomy or alcohol septal ablation surgery and percutaneous intervention go another round". J. Am. Coll. Cardiol. 49 (3): 358–360. doi: 10.1016/j.jacc.2006.10.029 . PMID   17239718.
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