Point: Alcohol Septal Ablation for Obstructive HCM

Liebregts M, Vriesendorp PA, ten Berg JM.
Alcohol Septal Ablation for Obstructive Hypertrophic Cardiomyopathy: A Word of Endorsement. J Am Coll Cardiol 2017;70:481-488.

Editor’s Note: See also the companion ASA HOCM counterpoint Journal Scan.

The following are key points to remember endorsing alcohol septal ablation (ASA) for obstructive hypertrophic cardiomyopathy (HOCM):

  1. Hypertrophic cardiomyopathy (HCM) is the most common inheritable cardiac disease, present in 1 in 500 of the general population.
  2. Approximately two-thirds of HCM patients have a significant gradient across the left ventricular outflow tract (LVOT) at rest or during physiological provocation, and are classified as having obstructive HCM (HOCM).
  3. First-line treatment in HOCM patients with significant LVOT obstruction is with negative inotropic drugs (beta-blockers, verapamil, and disopyramide).
  4. In the 5-10% of patients who stay highly symptomatic despite optimal medical therapy, septal reduction therapy is indicated, either by surgical myectomy or alcohol septal ablation (ASA).
  5. The initial performance of ASA was shrouded in safety concerns, due to the intracoronary injection of cardiotoxic ethanol, creating a potentially arrhythmogenic ablation scar.
  6. The 2011 American College of Cardiology Foundation/American Heart Association guidelines state that surgical myectomy is the gold standard for patients with medical therapy–resistant obstructive HCM, and that ASA should be reserved for elderly patients or patients with serious comorbidities.
  7. Despite these recommendations, recent figures show that approximately 43% of US patients undergo ASA instead of myectomy, and these numbers are known to be even higher in Europe. Based on these data, it is imperative to select the right patient for the right procedure.
  8. All care for HCM patients requiring septal reduction therapy should be confined to HCM centers of excellence where both procedures are available and are used in a complementary manner, instead of a competing one.
  9. To optimize outcomes and choose the right strategy, all patients undergoing septal reduction therapy should be discussed in a multidisciplinary heart team consisting of an imaging cardiologist, an interventional cardiologist experienced with ASA, and a surgeon experienced with myectomy.
  10. The latest innovation in ASA is three-dimensional myocardial contrast echocardiography–guided ASA and should be considered for selecting the correct septal branch.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound

Keywords: Ablation Techniques, Adrenergic beta-Antagonists, Cardiac Surgical Procedures, Cardiomyopathy, Hypertrophic, Comorbidity, Disopyramide, Echocardiography, Ethanol, Geriatrics, Heart Failure, Myocardium, Verapamil

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