Non-surgical myocardial reduction for hypertrophic obstructive cardiomyopathy

doi:10.1016/S0140-6736(95)91267-3

The Lancet

Volume 346, Issue 8969, 22 July 1995, Pages 211-214

https://doi.org/10.1016/S0140-6736(95)91267-3 Get rights and content

Abstract

Surgery has been the only therapeutic option in patients with hypertrophic obstructive cardiomyopathy who are resistant to drug treatment and sequential pacemaker therapy. I describe a novel catheter-based technique that may replace surgical myocardial reduction in some patients. The technique aims at selective destruction of the hypertrophied part of the left side of the intraventricular septum. If temporary occlusion of the first major septal artery is shown to reduce the intraventricular pressure gradient significantly, absolute alcohol is injected through the inflated balloon catheter to produce a localised infarct. In the first three patients treated with this method, the size of the septal infarct was sufficient to eliminate any subaortic stenosis immediately. Clinical improvement has been maintained up to 12 months. Non-surgical reduction of the septum in hypertrophic obstructive cardiomyopathy warrants further clinical evaluation.

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Cited by (703)

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In the 30 years since Dr Sigwart’s first pioneering procedures, alcohol septal ablation (ASA) has become the standard catheterisation procedure to reduce or eliminate obstruction in the left ventricular outflow tract. This procedure reduces the pressure gradient by 70%-80%, and only 10%-20% of patients have a residual gradient > 30 mm Hg after ASA. The mortality rate of the procedure is < 1%, and ∼ 10% of patients require permanent pacemaker implantation for higher degrees of atrioventricular block. Given the potential risks, ASA should be performed only in centres with extensive experience in the treatment of hypertrophic cardiomyopathy and with comprehensive therapeutic options, including myectomy. In the future, ASA is likely to be increasingly complemented by catheter-based mitral valve repair, which will increase its efficacy.
Au cours des 30 années qui ont suivi les premières interventions novatrices du Dr Sigwart, l’ablation septale à l’alcool (ASA) est devenue l’intervention par cathétérisme standard pour réduire ou éliminer l’obstruction dans la voie d’écoulement ventriculaire gauche. L’ASA réduit de 70 % à 80 % le gradient de pression; et seulement de 10 % à 20 % des patients affichent un gradient résiduel supérieur à 30 mmHg après cette intervention. Le taux de mortalité lié à l’intervention est inférieur à 1 %, et environ 10 % des patients ont besoin d’un stimulateur cardiaque permanent pour un bloc atrio-ventriculaire de degré supérieur. En raison des risques possibles, l’ASA doit être réalisée uniquement dans des établissements qui possèdent une vaste expérience dans le traitement de la cardiomyopathie hypertrophique et qui offrent une gamme complète d’options thérapeutiques, y compris la myectomie. L’ASA est susceptible d’être de plus en plus souvent accompagnée d’une réparation transcathéter de la valve mitrale, qui en augmentera l’efficacité.
Treatment With Microspheres in Patients With Obstructive Hypertrophic Cardiomyopathy: An Old Therapy Tries to Emerge With Long-Term Outcome Data
2023, American Journal of Cardiology
Invasive therapies for symptomatic obstructive hypertrophic cardiomyopathy
2023, Progress in Cardiovascular Diseases
Hypertrophic cardiomyopathy (HCM) is a genetic condition with multiple different genetic and clinical phenotypes. As awareness for HCM increases, it is important to also be familiar with potential treatment options for the disease. Treatment of HCM can be divided into two different categories, medical and interventional. Typically for obstructive forms of the disease, in which increased septal hypertrophy, abnormally placed papillary muscles, abnormalities in mitral valve or subvalvular apparatus, lead to dynamic left ventricular outflow tract (LVOT) obstruction, treatment is targeted at decreasing obstructive gradients and therefore symptoms. Medications like beta blockers, calcium channel blockers, disopyramide can often accomplish this. However, in patients with severe obstruction or symptoms refractory to medical therapy, either surgical correction of the LVOT obstruction or percutaneous via alcohol septal ablation, are treatment options. In this review, we will focus on the invasive treatment of hypertrophic obstructive cardiomyopathy.
Septal Microsphere Embolization in Hypertrophic Obstructive Cardiomyopathy
2023, American Journal of Cardiology
Alcohol septal ablation is an established treatment for selected patients with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction (LVOT). The safety and efficacy of septal microsphere embolization (SME) have not been studied. We conducted a retrospective analysis of SME procedures performed at our center from 2006 to 2021 using 75-µm microspheres. The primary end point was LVOT gradient reduction. Secondary outcomes included periprocedural mortality, conduction disturbances, access site complications, and duration of hospitalization. The population comprised 76 patients (median age 61 years, men 43%). Dyspnea New York Heart Association ≥III was present in 65 patients (86%); ventricular tachycardia and previous syncope were described in 4% and 18%, respectively. Median duration of hospitalization was 13 days, and the time to first follow-up was 4 months. SME resulted in a significant reduction at rest (41 vs 12 mm Hg, mean Δ PG = −71%, p <0.001) and provoked LVOT gradients (94 vs 29 mm Hg, mean Δ PG = −75%, p <0.001). Periprocedural death occurred in 1 patient (1%) who underwent SME after transcatheter aortic valve replacement. Complete atrioventricular block was observed in 5 patients (7%). Left bundle branch block was diagnosed in 1 case (1%) and right bundle branch block in 3 (4%). Access site complications were observed in 4 patients (5%). In conclusion, SME is a safe and effective alternative to alcohol septal ablation. The potential advantages of microspheres are still to be investigated in prospective studies.
Follow-Up of Up to 25 Years After Alcohol Septal Ablation for Obstructive Hypertrophic Cardiomyopathy
2023, JACC: Cardiovascular Interventions

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ArticlesNon-surgical myocardial reduction for hypertrophic obstructive cardiomyopathy

Abstract

Am J Cardiol

Am J Cardiol

Lancet

J Thorac Cardiovasc Surg

Am J Cardiol

Ann Thorac Surg

Ann Thorac Surg

Functional aortic stenosis: a malformation characterized by resistance to left ventricular outflow without anatomic obstruction

Circulation

Hypertrophic cardiomyopathy: continued progress

N Engl J Med

Hypertrophic cardiomyopathy: interrelations of clinical manifestations, pathophysiology, and therapy

N Engl J Med

Mapping a gene for familial hypertrophic cardiomyopathy to chromosome 14ql

N Engl J Med

Medical and surgical therapy of hypertrophic cardiomyopathy

Cardiovasc Clin

Relationship between preload and afterload and gradient in hypertrophic obstructive cardiomyopathy

Circulation

Verapamil-induced improvement in left ventricular diastolic filling and increased exercise tolerance in patients with hypertrophic cardiomyopathy: short and long-term effects

Circulation

Articles
Non-surgical myocardial reduction for hypertrophic obstructive cardiomyopathy