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Percutaneous Septal Ablation in Hypertrophic Obstructive Cardiomyopathy: From Experiment to Standard of Care.

Faber L - Adv Med (2014)

Bottom Line: Symptoms include exercise limitation due to dyspnea, angina pectoris, palpitations, or dizziness; occasionally syncope or sudden cardiac death occurs.Correct diagnosis and risk stratification with respect to prophylactic ICD implantation are essential in HCM patient management.Literature data and the own series of about 600 cases are discussed, suggesting a largely comparable outcome with respect to procedural mortality, clinical efficacy, and long-term outcome.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, University Hospital of the Ruhr University Bochum, Georgstraße 11, 32545 Bad Oeynhausen, Germany.

ABSTRACT
Hypertrophic cardiomyopathy (HCM) is one of the more common hereditary cardiac conditions. According to presence or absence of outflow obstruction at rest or with provocation, a more common (about 60-70%) obstructive type of the disease (HOCM) has to be distinguished from the less common (30-40%) nonobstructive phenotype (HNCM). Symptoms include exercise limitation due to dyspnea, angina pectoris, palpitations, or dizziness; occasionally syncope or sudden cardiac death occurs. Correct diagnosis and risk stratification with respect to prophylactic ICD implantation are essential in HCM patient management. Drug therapy in symptomatic patients can be characterized as treatment of heart failure with preserved ejection fraction (HFpEF) in HNCM, while symptoms and the obstructive gradient in HOCM can be addressed with beta-blockers, disopyramide, or verapamil. After a short overview on etiology, natural history, and diagnostics in hypertrophic cardiomyopathy, this paper reviews the current treatment options for HOCM with a special focus on percutaneous septal ablation. Literature data and the own series of about 600 cases are discussed, suggesting a largely comparable outcome with respect to procedural mortality, clinical efficacy, and long-term outcome.

No MeSH data available.


Related in: MedlinePlus

Angiographic ((a)–(c)) and echocardiographic ((d)–(f)) aspect of an echotargeted septal ablation procedure (in our practice denominated as PTSMA). A guidewire is advanced into the target vessel (arrows in (a)). Subsequently, an over-the-wire balloon is introduced. The correct position and fit of the balloon are verified by contrast injection (arrows in (b)) through the central catheter lumen. The vessel stump after alcohol injection and removal of the balloon is shown in (c) (arrows). In (d), the dotted circle marks the septal target area including the SAM-septal contact zone. Contrast injection into the target vessel (e) precisely highlights this area. After 3–6 months, akinesia and thinning of the subaortic septum are clearly visible, comparable to a myectomy trough.
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fig5: Angiographic ((a)–(c)) and echocardiographic ((d)–(f)) aspect of an echotargeted septal ablation procedure (in our practice denominated as PTSMA). A guidewire is advanced into the target vessel (arrows in (a)). Subsequently, an over-the-wire balloon is introduced. The correct position and fit of the balloon are verified by contrast injection (arrows in (b)) through the central catheter lumen. The vessel stump after alcohol injection and removal of the balloon is shown in (c) (arrows). In (d), the dotted circle marks the septal target area including the SAM-septal contact zone. Contrast injection into the target vessel (e) precisely highlights this area. After 3–6 months, akinesia and thinning of the subaortic septum are clearly visible, comparable to a myectomy trough.

Mentions: The septal ablation procedure produces a circumscript necrosis by injection of 96% ethanol (or other toxic agents; see below) into a septal perforator artery supplying the septal bulge involved in outflow obstruction (Figure 5). Several components of the procedure had earlier been tested or used clinically and in other scenarios. In the early 1980 years, the group of Sigwart reported on the effect of temporary balloon occlusion within a coronary vessel on myocardial function and thickening [100]. Brugada and coworkers, among others, used the injection of absolute ethanol into coronary arteries to eliminate arrhythmogenic foci [101]. The group of Kuhn and coworkers [102, 103] reported on temporary gradient reduction in HOCM following temporary balloon occlusion of septal perforator arteries. Even the use of intraprocedural contrast echocardiography had been outlined in a research proposal as early as 1989 [104]. Several acronyms have been introduced for the technique (in alphabetical order and probably incomplete): alcohol/ethanol septal ablation (ASA/ESA), nonsurgical myocardial reduction (NSMR), percutaneous transluminal septal myocardial ablation (PTSMA), or transcoronary ablation of septal hypertrophy (TASH), reflecting slightly different procedural strategies and/or operator preference.


Percutaneous Septal Ablation in Hypertrophic Obstructive Cardiomyopathy: From Experiment to Standard of Care.

Faber L - Adv Med (2014)

Angiographic ((a)–(c)) and echocardiographic ((d)–(f)) aspect of an echotargeted septal ablation procedure (in our practice denominated as PTSMA). A guidewire is advanced into the target vessel (arrows in (a)). Subsequently, an over-the-wire balloon is introduced. The correct position and fit of the balloon are verified by contrast injection (arrows in (b)) through the central catheter lumen. The vessel stump after alcohol injection and removal of the balloon is shown in (c) (arrows). In (d), the dotted circle marks the septal target area including the SAM-septal contact zone. Contrast injection into the target vessel (e) precisely highlights this area. After 3–6 months, akinesia and thinning of the subaortic septum are clearly visible, comparable to a myectomy trough.
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Related In: Results  -  Collection

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fig5: Angiographic ((a)–(c)) and echocardiographic ((d)–(f)) aspect of an echotargeted septal ablation procedure (in our practice denominated as PTSMA). A guidewire is advanced into the target vessel (arrows in (a)). Subsequently, an over-the-wire balloon is introduced. The correct position and fit of the balloon are verified by contrast injection (arrows in (b)) through the central catheter lumen. The vessel stump after alcohol injection and removal of the balloon is shown in (c) (arrows). In (d), the dotted circle marks the septal target area including the SAM-septal contact zone. Contrast injection into the target vessel (e) precisely highlights this area. After 3–6 months, akinesia and thinning of the subaortic septum are clearly visible, comparable to a myectomy trough.
Mentions: The septal ablation procedure produces a circumscript necrosis by injection of 96% ethanol (or other toxic agents; see below) into a septal perforator artery supplying the septal bulge involved in outflow obstruction (Figure 5). Several components of the procedure had earlier been tested or used clinically and in other scenarios. In the early 1980 years, the group of Sigwart reported on the effect of temporary balloon occlusion within a coronary vessel on myocardial function and thickening [100]. Brugada and coworkers, among others, used the injection of absolute ethanol into coronary arteries to eliminate arrhythmogenic foci [101]. The group of Kuhn and coworkers [102, 103] reported on temporary gradient reduction in HOCM following temporary balloon occlusion of septal perforator arteries. Even the use of intraprocedural contrast echocardiography had been outlined in a research proposal as early as 1989 [104]. Several acronyms have been introduced for the technique (in alphabetical order and probably incomplete): alcohol/ethanol septal ablation (ASA/ESA), nonsurgical myocardial reduction (NSMR), percutaneous transluminal septal myocardial ablation (PTSMA), or transcoronary ablation of septal hypertrophy (TASH), reflecting slightly different procedural strategies and/or operator preference.

Bottom Line: Symptoms include exercise limitation due to dyspnea, angina pectoris, palpitations, or dizziness; occasionally syncope or sudden cardiac death occurs.Correct diagnosis and risk stratification with respect to prophylactic ICD implantation are essential in HCM patient management.Literature data and the own series of about 600 cases are discussed, suggesting a largely comparable outcome with respect to procedural mortality, clinical efficacy, and long-term outcome.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, University Hospital of the Ruhr University Bochum, Georgstraße 11, 32545 Bad Oeynhausen, Germany.

ABSTRACT
Hypertrophic cardiomyopathy (HCM) is one of the more common hereditary cardiac conditions. According to presence or absence of outflow obstruction at rest or with provocation, a more common (about 60-70%) obstructive type of the disease (HOCM) has to be distinguished from the less common (30-40%) nonobstructive phenotype (HNCM). Symptoms include exercise limitation due to dyspnea, angina pectoris, palpitations, or dizziness; occasionally syncope or sudden cardiac death occurs. Correct diagnosis and risk stratification with respect to prophylactic ICD implantation are essential in HCM patient management. Drug therapy in symptomatic patients can be characterized as treatment of heart failure with preserved ejection fraction (HFpEF) in HNCM, while symptoms and the obstructive gradient in HOCM can be addressed with beta-blockers, disopyramide, or verapamil. After a short overview on etiology, natural history, and diagnostics in hypertrophic cardiomyopathy, this paper reviews the current treatment options for HOCM with a special focus on percutaneous septal ablation. Literature data and the own series of about 600 cases are discussed, suggesting a largely comparable outcome with respect to procedural mortality, clinical efficacy, and long-term outcome.

No MeSH data available.


Related in: MedlinePlus