Alcohol Septal Ablation
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Alcohol septal ablation is a percutaneous, minimally-invasive treatment performed by an interventional cardiologist to relieve symptoms and improve functional status in severely symptomatic patients with hypertrophic cardiomyopathy (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.
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[edit] History
Alcohol septal ablation was first performed in Britain at the Royal Brompton Hospital by Ulrich Sigwart in 1994. Since that time, it has quickly gained favor among physicians and patients alike due to its minimally-invasive nature, avoiding general anesthesia, lengthy recuperation and other complications associated with open heart surgery (septal myectomy).
[edit] 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. 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, a small amount of absolute alcohol is infused into the artery to produce a small heart attack. Patients typically experience mild chest discomfort during the procedure, which takes approximately 30 minutes to complete. Analesics 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 need for permanent pacemaker in 5-10%.
[edit] 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. 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.
When compared to surgical myectomy, similar outcomes are noted out to approximately 5 years.1 However, a prospective, randomized trial has not been performed. Despite initial concerns regarding long-term arrhythmic potential of alcohol septal ablation, no increased risk has been noted to date. It is important to note that patients who fail to respond to alcohol septal ablation may still be candidates for surgical myectomy. Likewise, patients who fail surgical myectomy may still respond to alcohol septal ablation.2
[edit] References
1. Ralph-Edwards A, Woo A, McCrindle B, Shapero J, Schwartz L, Rakowski H, Wigle E, Williams W (2005). "Hypertrophic obstructive cardiomyopathy: comparison of outcomes after myectomy or alcohol ablation adjusted by propensity score". J Thorac Cardiovasc Surg 129 (2): 351-8. PMID 15678046.
2. Juliano N, Wong SC, Naidu SS (2005). "Alcohol septal ablation for failed sugical myectomy". J Invasive Cardiology 17 (10): 569-71. PMID 16204755.
