INVASIVE INTERVENTIONS IN STRUCTURAL HEART DISEASES: COMPREHENSIVE TECHNIQUES

Invasive Interventions in Structural Heart Diseases-kapak

VENTRICULAR SEPTAL INTERVENTIONS: ALCOHOL SEPTAL ABLATION FOR OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY

Cemalettin Akman

Adıyaman University Training and Research Hospital, Department of Cardiology, Adıyaman, Türkiye

Akman C. Ventricular Septal Interventions: Alcohol Septal Ablation for Obstructive Hypertrophic Cardiomyopathy. In: Tanık VO, Özlek B, editors. Invasive Interventions in Structural Heart Diseases: Comprehensive Techniques. 1st ed. Ankara: Türkiye Klinikleri; 2025. p.473-480.

ABSTRACT

Hypertrophic cardiomyopathy (HCM) is a myocardial disorder characterized by left ventricular hypertrophy, primarily caused by sarcomeric protein gene mutations. This condition frequently leads to left ventricular outflow tract obstruction (LVOTO), affecting approximately 75% of patients. LVOTO is primarily due to systolic anterior motion of the mitral valve, driven by mechanisms such as the Venturi effect and papillary muscle displacement. In patients with an LVOT gradient exceeding 50 mmHg, septal reduction therapy is indicated, with alcohol septal ablation (ASA) emerging as a minimally invasive alternative to surgical myectomy. The ASA procedure begins with detailed imaging via transthoracic echocardiography or, if needed, transesophageal echocardiography to identify the hypertrophied basal septum responsible for LVOTO. The procedure involves the selective cannulation of the target septal artery using a guidewire, followed by placement of a balloon catheter. The balloon is positioned 1-2 mm distal to the septal artery origin and inflated to prevent ethanol reflux. Under real-time echocardiographic guidance, 1-3 ml of 100% ethanol is infused slowly over 1-3 minutes, inducing localized myocardial necrosis and reducing the hypertrophied septum’s thickness. The balloon remains inflated for an additional 5-10 minutes to stabilize the infarction. Angiographic imaging ensures the absence of reflux or damage to adjacent coronary vessels. Patients are closely monitored post-procedure in a cardiac critical care unit for 1-2 days. Continuous telemetry, daily ECGs, and cardiac biomarker assessments are performed to detect complications, such as atrioventricular block, which may necessitate pacemaker implantation. Acute procedural success is defined as a ≥50% reduction in LVOT gradients, with long-term benefits including symptom relief, improved exercise capacity, and ventricular remodeling. ASA is particularly effective for patients with localized septal hypertrophy ≤2.5 cm, offering outcomes comparable to surgical myectomy when performed in high-volume centers. Its minimally invasive nature, coupled with ongoing advancements in technique, continues to position ASA as a safe and effective option for obstructive HCM management.

Keywords: Hypertrophic cardiomyopathy; Left ventricular outflow tract obstruction; Alcohol septal ablation

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