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Alcohol Septal Ablation

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Alcohol Septal Ablation Interventional Imaging Cases Steven A. Goldstein MD Professor of Medicine Georgetown University Medical Center MedStar Heart Institute Washington Hospital Center Tuesday, October 10, 2017 DISCLOSURE I have N O relevant financial relationships Management Treatment Strategies for HCM No rx No symptoms ? drug rx B-blockers Symptoms Verapamil Disopyramide Refractory Symptoms Combined B-blockers and Ca-blockers Refractory, Severe Sx Obstruction Non-obstruction Myotomy-Myectomy Transplant ??? DDD-pacing ETOH septal ablation HCM121 Drug-Refractory HCM Therapeutic Options Surgery Dual-chamber Septal pacemaker Ablation Alcohol Ablation Alcohol Septal Ablation • 1994 – 1st procedure at Royal Brompton • Since then >10,000 performed HCM - Alcohol Septal Ablation Indications • NYHA Class III nor IV* (*unresponsive to maximum medical treatment) • LVOT gradient > 50 mmHg at rest (or with physiologic provacative maneuvers) • ≥ 1 septal branch of LAD suitable for intervention HCM - Alcohol Septal Ablation Selection Criteria • Symptoms that interfere substantially with QOL despite optimal medical mgt • Septal thickness ≥ 1.6 cm • LVOT gradient ≥ 30 mm Hg at rest or ≥ 50 mmHg with provocation • Accessible, appropriate septal perforator(s) • Absence of intrinsic MV abnormality • Absence of other conditions warranting cardiac surgery HOCM - Alcohol Septal Ablation Echo Methods for Guidance Majority • Transthoracic echo (TTE) of centers • Transesophageal echo (TEE) WHC* • Intracardiac echo (ICE) * Moderate sedation; NOT general anesthesia HOCM - Alcohol Septal Ablation TEE Views • Apical 4-chamber view (0°) • Longitudinal view (120-130°) • Gastric short-axis view • Deep transgastric view (for gradient) Hypertrophic Cardiomyopathy Alcohol Septal Ablation Using intracoronary injection of an echo contrast agent, opacification of the strategic septal area can be delineated. Alcohol Ablation of Septum in HCM Echo in Cath Lab During Procedure Transesophageal Transthoracic HOCM - Alcohol Septal Ablation Echo Guidance During Procedure Myocardial Contrast Echo (Intracoronary Contrast) Goal: Delineate strategic portion of septum (perfusion territory of target septal perforator) HCM - Alcohol Septal Ablation Similar to surgical myectomy, this procedure attempts to debulk the septum in the region where the LVOT obstruction occurs A localized myocardial infarction is created by injecting ethanol into the septal perforator that supplies the septal myocardium adjacent to the point of mitral leaflet (SAM)-septal contact Alcohol Ablation of Septum in HCM Ethanol-induced infarction Nishimura and Holmes N Engl J Med 350:1320(2004) HOCM - Alcohol Septal Ablation What to Evaluate Pre-Procedure • Site and extent of septal hypertrophy • Intracavitary gradient • Localization of SAM-septal contact • Mitral regurgitation (mechanism and degree) "An important improvement of the new method in our opinion has been gained by the integration of echo monitoring" Faber, Seggewiss, et al Circulation 98:2415(1998) Septal Ablation in HCM Contrast Echo Helps Improve Results p<0.01 p<0.05 100 97 No Contrast (n=30) 92 Contrast (n=91) 80 86 60 70 40 % Patients % 20 0 >50%reduction Clinical in LVOTG improvement Faber, Seggewiss Circulation 98:2415(1998) HOCM - Alcohol Septal Ablation Echo Guidance During Procedure Assess Immediate Results • Reduction of contractility/thickening of septum • Elimination/reduction of SAM • Elimination/reduction of gradient • Elimination/reduction of mitral regurgitation HOCM - Alcohol Septal Ablation Follow-Up (Post-Procedure Echo) • LVOT gradient • Mitral regurgitation • Diastolic Filling • Regression of hypertrophy • LV function (especially septum) HOCM - Alcohol Septal Ablation Echo Guidance During Procedure Myocardial Contrast Echo (Intracoronary Contrast) Goal: Delineate strategic portion of septum (perfusion territory of target septal perforator) Alcohol Ablation of Septum in HCM Echo in Cath Lab During Procedure Transesophageal Transthoracic Case 1 Case 2 MM - 61 year-old man Case 3 Case 4 Case 5 BP - 69 year-old female Aborted RV papillary muscle perfused Pericardiocentesis Pericardiocentesis Using Subxiphoid Approach “Old-Fashioned Way” alligator clip to ECG Echo-Guided Pericardiocentesis • Gold-standard for management of effusions reguiring drainage • Improves success rate • Improves safety • Reduces complication rate Location of Needle Entry Chest wall (79%) Para-apical 67% L parasternal 6% L axillary 4% R parasternal 2% Posterolateral 0.2% n = 1,131 Unknown Subcostal Mayo Clinic: courtesy Seward/Khandheria Needle Attempts for Access PC (%) n = 1,131 Number of needle attempts Mayo Clinic: courtesy Seward/Khandheria Success and Complications of (Consecutive 1,131 procedures) Successful PC 1,097 (97%) Major complications 16 (1.4%) Death 1 Ventricular laceration 6 Intercostal vessel injury 1 Pneumothorax 6 Ventricular tachycardia 1 Infection 1 Minor complications 37 (3.3%) Mayo Clinic: courtesy Seward/Khandheria Management of Cardiac Tamponade • 1978 Blind pericardiocentesis • 6% mortality, 50% morbidity • Echo-guided centesis: n = 1,131 • <0.1% mortality, <2% morbidity Mayo Clinic: courtesy Seward/Khandheria Pericardiocentesis • Call 7-6146 for Microbiology to tube • Complete blue FLUID lab 2 aerobic culture specimen bottles to slip with: the front desk # 205 • Cell count (purple tube) • Elevate HOB with wedge @ 45° • 1 air tight 20 cc syringe • Chest prepped and draped (capped) • Page echo stat to Cath Lab (7-6700) • Gram stain • Sedate as ordered • AFB smear and culture • Closely monitor HR & BP • Aerobic, anaerobic cultures • Drop (2) 20cc syringes for labs • Fungal culture • Obtain CCU or ICU bed • Cytology • Patient may be sent to a 4th floor • Glucose cardiac bed if hemodynamically • Total protein stable • Albumin • LDH • Adenosine deaminase Apical Approach Apical-Lateral Approach Case 1 JC - 55 year-old woman Contrast confirms Case 2 EW - 80 year-old woman Apical approach pericardiocentesis site (apical) Not optimal Case 3 TJ - 71 year-old man Pericardiocentesis L-axillary approach pericardiocentesis site (subaxillary- lateral)) Not optimal Case 4 RD - 77 year-old man Massive pericardial effusion .
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