Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy

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Alcohol Septal AblationinHypertrophic
Obstructive Cardiomyopathy

• John F. Robb, MD
• Associate Professor of Medicine
• Director, Cardiac Catheterization Laboratories

December 6, 2004
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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, lt 1 flight, lt1 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

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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

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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

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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 gt 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.

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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.

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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

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Alcohol Septal Ablation

• Case Presentation
• EKG

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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

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Alcohol Septal AblationPre Echo
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Alcohol Septal AblationPre Echo
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Alcohol Septal AblationPre Echo
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Alcohol Septal AblationPre Echo
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Alcohol Septal AblationHemodynamics Pre
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Alcohol Septal AblationHemodynamics Pre
RV Pacing
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Alcohol Septal AblationCath angio
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Alcohol Septal Ablation Cath angio
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Alcohol Septal Ablation Cath angio
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Alcohol Septal AblationEcho Procedure
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Alcohol Septal AblationHemodynamics post
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Alcohol Septal AblationEcho Procedure
Post
Pre
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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

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Alcohol Septal Ablation

• Case Presentation
• Post EKG

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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

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Alcohol Septal AblationEcho 180 days post
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Alcohol Septal AblationEcho 30 days post
Rest
Valsalva
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Alcohol Septal Ablation

• Case Presentation
• 30 day EKG

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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

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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

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Alcohol Septal AblationEcho 30 days post
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Alcohol Septal AblationEcho 180 days post
Rest
Valsalva
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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 lt 25 mmHg at time of procedure
• CK 1300

Spencer, JACC 2002 Spencer, Circulation 2004
109824
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Alcohol Septal AblationOutcomes
Spencer, JACC 2002
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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

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Alcohol Septal Ablation
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Alcohol Septal AblationTherapy
Holmes, NEJM 2004 3501320
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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.

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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
• PVCs
• Dobutamine or isoproterenol
• Exercise

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Alcohol Septal AblationHemodynamics post
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Alcohol Septal AblationHemodynamics post
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Alcohol Septal AblationHemodynamics post
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Alcohol Septal AblationHemodynamics post
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Alcohol Septal AblationHemodynamics Pre
Valsalva