Alternative techniques to alcohol septal ablation for hypertrophic obstructive cardiomyopathy
Summary
Alcohol septal ablation (ASA), an efficacious treatment to relieve obstruction in patients with hypertrophic obstructive cardiomyopathy, has several drawbacks among which are the occurrence of complete heart block, alcohol diffusion to non-targeted areas and the possible pro-arrhythmogenic nature of the alcohol-induced scar. Alternative techniques have emerged with the aim of lowering complication rates and improving outcomes of catheter-based septal ablation. Non-alcohol septal embolisation techniques (coil embolisation, polyvinyl alcohol foam particle injection and cyanoacrylate septal injection) consist of embolising the septal perforator artery with material less viscous than alcohol. The procedural success rates reported were high (90-100%), with significant and persistent reduction in the left ventricular outflow tract (LVOT) gradient up to 6 months follow-up. No permanent complete heart block (CHB) was reported in the described series. Direct endocavitary ablation of the hypertrophic septum can be achieved by radio frequency or cryotherapy (Endocardial Radiofrequency Ablation of Septal Hypertrophy, ERASH, or Percutaneous Transvalvular Endomyocardial Septal Cryoablation, PTESC). ERASH resulted in a significant and sustained reduction in resting LVOT gradient but a similar rate of CHB as with ASA (21%), despite mapping of the His bundle during the procedure and a small infarct size.
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