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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 AblationinHypertrophic 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 • 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 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 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 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 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 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
Alcohol Septal Ablation Case Presentation • EKG:
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
Alcohol Septal AblationHemodynamics Pre RV Pacing
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 Ablation Case Presentation • Post EKG
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 AblationEcho 30 days post Rest Valsalva
Alcohol Septal Ablation Case Presentation • 30 day EKG:
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 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 AblationEcho 180 days post Rest Valsalva
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 AblationOutcomes Spencer, JACC 2002
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 AblationTherapy Holmes, NEJM 2004 350:1320
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 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
