Chapters Transcript Video Alcohol Septal Ablation to Treat HCM So I'm Matt Summers. I'm the program director of Structural Heart. And this is a 65 year old gentleman that had uh it came from another hospital system, but he had a history of a prior stent and then what was told to us to be a long standing murmur, murmur and he had progressive shortness of breath. So on the picture, on the left, you'll see this parasternal long axis echocardiogram, you can see um similar pictures to what's been shown in the session already. There's a very, very thick upper septum. You can see the arrow sign there pointing to that. There's also systolic anterior motion or S A of the anterior mitral leaflet. It's coral sam, there is septal contact, but you can see that bulge of muscle creates an obstruction to outflow from the heart's main pumping chamber, the left ventricle uh to the aorta. And uh as doctor b uh pointed out there's several conditions in which that obstruction becomes dynamic and changes in severity. We see it uh in physical exam maneuvers with valsalva, we can use amal nitrate or, or uh in the Cath lab, we use uh iono tr to make it worse uh or use afterload reduction agents, nitroglycerin, um or Nipride uh to provoke these obstructions. But ultimately, we screen for it on echocardiogram. So it's our most important test. So 2.4 centimeter septum and we had peak velocity of up to 7.2 m per second. So a gradient in the left ventricle between the left ventricle and the aorta of over 200 millimeters of mercury. This is the representative cardiac MRI. You can see that upper septal uh uh hypertrophy. You can see some of the coral again, not the leaflet with the cordial uh systolic anterior motion. Um We mentioned some of the risk factors for sudden cardiac death. This patient had 9% scar and a 2.2 centimeter upper septum. And then this is uh for the Cath lab tech I, when we're doing these studies, it's always interesting to me uh sometimes interesting to them uh that you have both resting gradients and also provocable gradients. So just like we can do on physical exam, I can have the patient bear down, they're usually sedated. So it's a little bit more difficult to do. But one of the main ways that we provoke these dynamic gradients is by inducing PV CS with our pig tail. And so I have a catheter that's in the left ventricle. And on the other end of that catheter, I have a pressure wave form that's in the aorta and I can tap the ventricle, which you see in that middle screen cause a couple of extra beats and then the compensatory pause that happens after that allows a lot of calcium to influx into the cells. And that causes a more forceful contraction and increased stroke volume within the next cycle and a normal heart. But if you increase contractility, doctor bot I mentioned that that will worsen your, your outflow tract obstruction. So we can see that in real time uh with our wave forms in the Cath lab is that we have a post PV C gradient of over 200. That's exactly what we saw on the echocardiogram with the, the spectral analysis. Uh the Doppler. Uh what you'll notice here is that there's a very good septal perforator. We found his old stent is in a diagonal uh that was open, there is some moderate disease right at the bifurcation of uh that diagonal uh uh branching diagonal in the mid led. So this gentleman as we talked about was started on beta blockers and the calcium channel blocker. Um He had a treadmill test. Um that was more prognos, prognostic. We used to do a little bit more commonly look for uh abnormal blood pressure response to exercise and, and hypotension. Um He was started on a do a after a demonstration of atrial fibrillation on his monitor, he had no sustained VT on that monitor, no of the risk factors for sudden cardiac death. Um But he continued to have symptoms one year after his diagnosis. And importantly, he had symptom uh refractory, uh class three symptoms, refractory to beta blockers and calcium channel blockers. And so we took him for alcohol ablation. The important thing to note is in some older studies, 20% of pa uh patients that get alcohol ablation need a pacemaker. So one in five, it's a little bit lower than that nowadays, it's 10 to 15%. But the first image here in the upper left is me putting in a pacemaker. Uh These patients have to sit in the IC U for 48 hours because the risk of pacemaker uh in complete heart block is persistent. During those first two days, I do these bi radial. So through both radial arteries from the left, I have a four French uh pig tail. It sits in the LV. Uh And from the right, I have my PC I guide. So you can see that in the middle screen that I'm taking a picture of the uh uh left Maine. And you can see on the far upper right uh Coronary wire that's advancing into the septal one. So S one arcade and I have that uh through and what's called an over the wire balloon. So a tiny little catheter that has a balloon on it, that can include blood flow into that septal perforator. You can see that in the lower left, that balloon is inflated and I'll show you some wave forms for that. Once that's inflated, I can prevent the reflux of anything uh back into the main blood vessel. So this is how septal ablations have been performed for more than 20 years. But what we do is we include that balloon, uh it's a 15 to 2, a balloon and septal. And we can actually see with the akinesis and the hypokinesis that, that induces improvement gradients just as the balloon inflates. One of the reasons I enjoy this procedure is I get to do it with our echo text and our Cath lab text, it's multimodal. And so our echo texts are also in the room in the middle screen there, I'll inject definity. So an echo uh contrast into that same balloon catheter and I can see the area of the septum light up with definity on echocardiogram. Such that I know that that blood vessel is, is limited to that territory where I'm causing a controlled heart attack. When doctor uh Patel does an ablation, he's talking about correcting electrical arrhythmia. And most of the time I'm fixing heart attacks and putting stents in. But this is the one rare occasion where we're actually uh causing a controlled heart attack in a blood vessel. And so it's important that we uh determine exactly the territory in which that septal perforator feeds. And so we did that, we, we do definity and then we inject uh one CC at a time sometimes half CC at a time, uh basically 99% ethanol. And you typically go up to one cc of that per centimeter of the septum. And so he was 2.2 centimeters. Uh but you can see in the middle bottom, uh that septal perforator is now occluded, there's barely any flow into it. And in the bottom, right, you see an LV gram that shows akinesis in the upper septum. This is why I enjoy this procedure. Um because of the multi multi modal uh modal uh sorry, this isn't going there we go. The uh multimodal imaging that's uh involved in the upper left. You can see the arrow is showing that thick upper septum and you can see a post PV C grading of over 200 on echo and C with balloon occlusion that goes to about 100. So cut in half. You can see the thickness of that septum there with balloon occlusion. You can see how it becomes hypokinetic with definity echo contrast. You can see that upper septum uh light up with the, the definity contrast, which we usually uh used to outline the, the endocardium after one CC of alcohol, alcohol, the the gradients go to 50 to 60 after two CCS they went to 25 and so had a pretty significant reduction in these outflow tract obstructions and this was the final result. So he's been asymptomatic for two years since he had an echo. I looked and followed up on uh him in June, he had a peak gradient uh at rest of of 20 his Valsalva went to 35 so 200 millimeters to 35 2 years out. Uh asymptomatic is pretty remarkable resolve for him. So, very quickly, I'll go through the justification for this and the rationale. There's two ways we talked about, I think about Mava Campton as medical uh septal reduction therapy. Uh But we've had these two forms of septal reduction therapy for, for decades. Uh extended uh septal myectomy, which is a surgical procedure where the, the muscle is actually thinned and cut and shaved or percutaneous septal reduction reduction therapy, which is almost always alcohol sepal ablation. But I'll show you some of these others that uh have been attempted in the past, the takeaway generally is that if you're a good candidate for surgery or have another surgical indication, you should get uh myectomy. And the, the data has shown that there's less recurrence of outflow obstruction. Um There's pretty similar mortalities. They're not directly compared uh through five years. They may separate at 10 years and that may be from some selection bias. But the big differentiators are, you may have to come back and do it again if you do a percutaneous septal reduction and you're very likely to get a pacemaker, much more likely to get a pacemaker. This is Doctor S Madeira and uh at the Cleveland clinic doing a septal myectomy. So you can see um he literally looking down the aorta and shaving that muscle. This is a, an uh animation that's demonstrating that as well where you shave the muscle. This procedure is largely developed at Mayo Clinic and Cleveland Clinic uh by folks like doctor Cosgrove and his colleagues. And this is an alcohol septal ablation, which is what, what I do at depo does. Um It's a structural heart procedure. We take a catheter into that septal perforator inflate a balloon. One of the best prognostic signs for whether this is gonna work is how much the gradient reduces when you inflate the balloon. So we can tell right away even before we cause a heart attack. Uh what kind of result we're anticipating, getting and to the right. You'll see the, the data that was from 2015, a big meta analysis. You can see once you adjust for um competing risks, they're, they're pretty similar. And that's why the guidelines in 24 gave the option for you can go straight to alcohol ablation if you don't have another surgical indication like a concomitant mitral procedure to do. The other things you can do. I do a lot of uh coronary artery and other blood vessel coiling. You can coil the septal as a way to include them. And then the scorpion which doctor uh um uh Patel is uh mentioned in his, at the end of his presentation is something we'll show this afternoon as well. So, the take home is that these therapies are reserved for people that have drug refractory symptoms. Um, and I thought we would do significantly less of these once Mac Canton came out a few years ago, I told patients that I was probably doing my last alcohol ablation before we got approval. It, it's maybe cut it in half. We do about a half a dozen a year. It's not very common anymore. Uh, before Mava Canton it was probably a dozen or more a year. All right. Thank you. Published November 14, 2024 Created by Related Presenters Matthew Summers, M.D. Sentara Cardiology Specialists View full profile
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