Alcohol Septal Ablation (ASA) Key Points • For HOCM patients with persistent symptoms, open- surgery Annapoorna S. Kini, MD and surgical removal Hypertrophic obstructive cardiomyopathy (HOCM) medical management while septa thicker than 26mm of the overgrown heart is typically genetic in nature and reveals itself in the should not undergo ASA. muscle (myectomy) is the recommended treatment. second or third decade of life. Patient complaints ASA is performed percutaneously, eliminating the include exertional chest pain, shortness of breath, need for surgery, but yields similar results in terms of • Mount Sinai’s Catheterization fatigue, fainting, and palpitations. Rarely, sudden removing overgrown heart muscle. This procedure Laboratory offers a minimally death can occur. There are a range of treatments involves injecting 98 percent alcohol via invasive procedure known available for symptomatic HOCM. First-line treatment into a carefully selected artery that supplies blood as consists of medical management with drugs such as to the overgrown tissue in the enlarged septum. The (ASA) to a select group beta-blockers, calcium channel blockers, and other highly-concentrated alcohol is injected slowly (1-3cc/ of HOCM patients with negatively inotropic medications (drugs that slow the second) directly into the heart muscle and is left in refractory symptoms. heart rate and improve the filling of heart). For patients place for several minutes. The treatment effect starts with persistent symptoms, the recommended treatment immediately by causing controlled cell death at the • This procedure involves a slow injection of 98 is open-heart surgery and surgical removal of the target location. Typically, the goal is to remove no percent alcohol via catheter overgrown heart muscle () to enhance more than two grams of obstructive muscle mass, as in a carefully selected blood flow from the left . complications such as irregular heart beat can occur artery supplying blood to The Mount Sinai Laboratory is if a more aggressive approach is used, necessitating a the overgrown tissue in one of the relatively few high-volume centers offering permanent pacemaker. Strict adherence to our highly the enlarged septum. a select group of HOCM patients with refractory or cautious patient selection protocols, complemented persistent symptoms another choice, alcohol septal by extremely efficient post procedure management in • Recent reports have ablation (ASA). This minimally invasive procedure does CCU, has helped optimize our outcomes. suggested that improvement not require general anesthesia or lengthy recovery time Following the procedure, patients are closely monitored of left ventricular outflow gradients with ASA and is rarely associated with complications of open- in ICU for two days with a temporary pacemaker improves prognosis of these heart septal myectomy. inserted via the jugular vein in the neck with particular patients, and results are While selecting patients for this procedure, we follow attention paid to heart rhythm and changes in blood comparable to myectomy. certain standards based on echocardiographic chemistry. Approximately 10 percent of the patients assessment of the hypertrophic heart muscle. after ASA will require a permanent pacemaker due • While selecting patients for Thicknesses less than 16 mm typically respond to to persistent heart block. Patients typically report this procedure, we follow immediate improvement in their symptoms and once certain standards based safely stabilized, are able to go home with minimal on echocardiographic restriction on physical activity for the following two assessment of the to four weeks. The ablative process completes over hypertrophic heart muscle. several weeks as a thin layer of scar tissue forms and LV diastolic function improves. We do follow-up echocardiograms of the post-operative patient in three to six months.

Reference: Alcohol septal ablation for the treatment of hypertrophic obstructive cardiomyopathy: A multicenter North American Registry. J. Am Coll Cardiology 2011; 58: 2322-8.

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