Alcohol Ablation Research Articles

The role of cardiac catheterization in solving the issue of surgical treatment of symptomatic hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is an underdiagnosed genetic heart disease with a prevalence of 0.2–0.5 %. Although the prognosis of HCM is relatively favorable, the annual overall mortality is about 0.7 %. The most common complication of HCM is obstruction of the left ventricular outflow tract (LVOT). Careful diagnosis and timely identification of high-risk patients by confirming the presence and degree of obstruction of the left ventricular outflow tract may reduce morbidity and mortality due to timely and correctly selected treatment. One-third of patients with HCM have echocardiographically confirmed LVOT obstruction at rest, and another third may have LVOT obstruction with provocation. Our clinical case demonstrates the presence of a small group of patients with HCM, whose LVOT obstruction is underestimated by transthoracic echocardiography (TTE) neither at rest nor when using provocative tests (Valsalva tests, exercise), and its hemodynamic significance is revealed only with invasive hemodynamic catheterization of the heart. Below, we illustrate the utility of hemodynamic catheterization as an adjunctive tool to echocardiography to help establish the presence, magnitude, and location of obstruction in patients with HCM in the absence of such data on TTE. In case of a high degree of suspicion that LVOT obstruction is responsible for refractory symptoms, catheterization can establish the presence of a hemodynamically significant LVOT gradient and, accordingly, without deviating from clinical recommendations, to carry out optimal surgical treatment, in our case – septal alcohol ablation with subsequent elimination of symptoms and restoration of the patient’s endurance to physical exertion.

Benign Bone Tumors: State of the Art in Minimally Invasive Percutaneous Interventions

Painful benign bone tumors most commonly affect pediatric patients and young adults. They may be associated with skeletal-related events such as intractable pain, pathologic fracture, neurologic deficit as a consequence of nerve or spinal cord compression, as well as growth disturbance. Consequently, they often result in diminished activity and adversely affect quality of life. There have been substantial recent advances in percutaneous minimally invasive image-guided interventions for treatment of painful benign bone tumors including thermal ablation (radiofrequency ablation, cryoablation, microwave ablation, laser photocoagulation, and high-intensity focused US ablation), chemical (alcohol) ablation, cementoplasty, and intralesional injections. The safety, efficacy, and durability of such interventions have been established in the recent literature and as such, the role of musculoskeletal interventional radiologists in the care of patients with benign bone lesions has substantially expanded. The treatment goal of minimally invasive musculoskeletal interventions in patients with benign bone tumors is to achieve definitive cure. The authors detail the most recent advances and available armamentarium in minimally invasive image-guided percutaneous interventions with curative intent for the management of benign bone tumors. © RSNA, 2022.

Abstract 14714: Marked Gradient Reduction Through a Transcoronary Alcohol Ablation of Septal Hypertrophy in a Patient With Cardiac Amyloidosis and Hypertrophic Cardiomyopathy

A 66-year-old male with a history of carpal tunnel syndrome and hypertension presented with dyspnea (NYHA III), angina pectoris, and sinus bradycardia. On clinical examination, the patient was stable and euvolemic. A systolic murmur (III/VI) was audible in the 4th left intercostal space laterally, augmented after a Valsalva maneuver. An electrocardiogram revealed normal sinus rhythm, heart rate of 81 bpm, normal voltage, and non-specific ST-changes in I, II, III, aVF, V5, and V6. The patient underwent a transthoracic echocardiography, which revealed thickened ventricular walls (IVSd 23 mm, PWd 20 mm), hyperdynamic left ventricular ejection fraction (LVEF 75%), LVOT gradient of 150 mmHg maximum (after Valsalva maneuver), apical sparing on strain analysis, and a dilated atria. A coronary angiography ruled out coronary artery disease. A endomyocardial biopsy revealed hypertrophic cardiomyopathy combined with focal cardiac amyloidosis (Figure 1). Subtyping and genetic analysis revealed transthyretin (ATTR) wild-type amyloidosis. Accordingly, therapy with Tafamidis 61 mg daily was initiated. Given the relevant amount of hypertrophy depicted on the biopsy samples, the high LVOT gradient, and the patient’s debilitating symptoms despite maximal medical therapy, the decision was made to attempt a transcoronary alcohol ablation of the septal hypertrophy (TASH). The TASH reduced the LVOT gradient from 150 mmHg to 35 mmHg. After the procedure, the patient experienced significant symptom improvement (NYHA II) and was discharged the next day. This case illustrates the feasibility of marked LVOT gradient reduction in patients with amyloidosis and hypertrophic cardiomyopathy through a TASH procedure. Figure 1: Histology reveals hypertrophic cardiomyocytes and cardiac amyloidosis on Congo red staining.

Management of Aggressive Vertebral Haemangioma and Assessment of Differentiating Pointers Between Aggressive Vertebral Haemangioma and Metastases - A Systematic Review.

Systematic review. Vertebral haemangioma has been classified into typical and aggressive vertebral haemangioma (AVH). Management options for AVH are many and the clinician has decision dilemma in choosing the right one. Metastases mimic AVH in clinical and radiological presentation. Differentiating pointers between them has not been clearly delineated in literature. Aim of our review is to identify treatment options; to formulate a management algorithm for AVH based on clinical presentation and to identify radiological differentiating pointers between them. Systematic review was conducted according to PRISMA guidelines. We systematically reviewed all available literature from the year 2001 to 2020. Relevant articles were identified as per laid down criteria from the medical databases. After inclusion, first and second authors went through full text of each included article. Of 139 studies reviewed, eight met our criteria for review of management and three separate studies for radiological differentiating pointers. 99 patients with 88 AVH had undergone treatment. Back pain with myelopathy is the presenting symptom in majority of patients. Patients with backpain - myelopathic symptoms had improved following surgery; patients with back pain alone had improved with either percutaneous vertebroplasty or CT guided alcohol ablation. Dynamic contrast MRI, Diffusion weighted MRI and ratio of signal intensity between T1w and fat suppression T1w MR help the clinician in differentiating them. Management of AVH can be based on the patient's clinical presentation. Patients presenting with AVH and back pain can be managed with either Percutaneous vertebroplasty or CT guided alcohol ablation. Patients presenting with AVH and neurological symptoms could be managed with surgery. Dynamic contrast enhanced MR, Diffusion weighted MR, ratio of signal intensity between T1w and Fat suppression T1w MR imaging could help the clinician in differentiating the two before contemplating biopsy. C.

3 year outcomes of permanent pacemaker implantation after alcoholic septal ablation

Abstract Introduction Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy are often submitted to alcohol septal ablation (ASA). One of the most frequent complications is the complete hear block (CHB), requiring permanent pacemaker (PPM) in variable rates, up to 20% of the patients. The long-term impact of PPM implantation in these patients remains unclear. Objectives This study aims to evaluate the long-term clinical outcomes in patients who implant PPM after ASA. Methods In a tertiary center, patients who underwent ASA were consecutively enrolled prospectively. Patients with previous PPM or implantable cardio-defibrillator were from this analysis. The groups with and without PPM implantation after ASA were compared regarding baseline characteristics, procedure data and 3-year primary and secondary endpoints. Results Between 2009 and 2020, 109 patients underwent ASA. 97 patients were included in this analysis (68% female, mean age 65.2 years-old). 16 patients (16.5%) required PPM implantation for CHB. In those, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics regarding comorbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with statistically significant differences in the mean age (70.6y/o in the PPM group versus 64.1y/o) and in the beta-blocker therapy rates previously to the intervention (56% in the PPM group versus 84%). Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692U/L versus 1243U/L, p0.05), without significant differences in the alcohol dose (2.1ml in both groups, p0.33). At 3 years after ASA procedure, the primary endpoint (composite of all-cause mortality and all-cause re-hospitalization) showed a statistical tendency to a lower event rate in the group who implanted PPM (p-value 0.097, Graphic 1). The secondary endpoint (composite of all-cause mortality and cardiac cause re-hospitalization) did not show any significant statistical difference between the two groups (p-value 0.216, Graphic 2). Conclusions The long-term endpoint analysis suggests that the outcomes in patients who implant PPM after ASA are non-inferior to those who do not, with a tendency to a lower rate of the endpoint composite of all-cause mortality and all cause re-hospitalizations. Funding Acknowledgement Type of funding sources: None.

Association between obesity and hypertrophic cardiomyopathy phenotype, validation in a latin american cohort

Abstract Objectives Hypertrophic Cardiomyopathy (HCM) is the most common genetic cardiomyopathy. The influence of obesity on the disease phenotype is not well established. A recent publication sought to answer this gap. Our objective is to assess the relationship of a obesity on the phenotype of our cohort and compare it to the published literature. Methods We performed a retrospective observational study of consecutive patients diagnosed with HCM at a single center in Argentina. We included 1331 patients between March 1993 and December 2021. We excluded patients <18 years of age, metabolic diseases & syndromes and patients who were lost on follow up. We defined Obesity as a body mass index ≥30 kg/m2. Results 1168 patients had available data for analysis. 54 (10.4%) patients were obese. Mean age was 54±28 years and 33 (61%) were male. Average maximal left ventricular wall thickness (LVWT) in this group was 20 mm ± 5 mm. When comparing obese vs non-obese patients we found no statistically significant differences for gender, age, family history of HCM, family history of sudden death (SD), previous VF/VT/NSVT, ESC low, intermediate or high risk for SD groups, fibrosis, apical aneurism, LV diameter, maximum LVWT, high risk genetic mutation, abnormal BP response to exercise, device implant, septal alcohol ablation, reduced EF on follow up, nor death/HF/Stroke/AICD appropriate therapy/AF development. We did find that obese patients had less unexplained syncope (6% vs 13%, OR 0.43, p=0.03), had more frequently an NYHA > III/IV (15.3% vs 8.9%, OR 1.8, p=0,03), a trend to having less frequently a LVWT >30 mm (3.5% vs 8.1%, OR 0.41, p=0.07) but more frequently had systolic anterior motion of the mitral valve on echocardiography (45% vs 34%, OR 1.58, p=0.04). We noted a trend to being more frequently indicated LV myectomy (9.2% vs 5%, OR 1.9, p=0,07) and significantly having elevated ultrasensitive troponin I (7.8% vs 3.7%, OR 2.2, p=0,04). Conclusions We found that obese patients from our cohort, as described in other series, had more advanced symptoms. In our set of obese patients they were more frequently sent to myectomy rather than alcohol septal ablation as described in other series. AF was not more prevalent among our obese patients and maximum wall thickness and fibrosis were not higher either. We did find that obese patients had more frequently elevated biomarkers. As HCM is so frequent it is important to characterize cohorts and compare data. Funding Acknowledgement Type of funding sources: None.

HYPERTROPHIC CARDIOMYOPATHY WITH OBSTRUCTION OF THE LEFT VENTRICLE

It is a septal hypertrophy, asymmetric type, causing left ventricular outflow obstruction due to thickening of the left ventricular wall; this pathology has a worldwide prevalence of 0.02-0.23%; and it is the most important cause of sudden death in young people. It is characterised by myocardial hypertrophy leading to diastolic dysfunction; epidemiologically, it occurs equally in men and women, although women tend to be more symptomatic, more disabled and present at a younger age. The patient may be asymptomatic or may present with dyspnoea, precordial pain and syncope. For diagnosis, chest X-ray, electrocardiogram and echocardiography may be used; MRI and cardiac catheterisation only in cases to identify the aetiology and severity of the disease. For treatment, background medication such as beta-blockers may be used, or alcohol ablation techniques may be performed. However, in some cases, pacemakers or implantable defibrillators may be needed. The aim of this literature review is to provide information on this pathology, which, despite not being so common in our environment and being more of a speciality of Cardiology, there is the possibility of presentation in young people, and that, presenting cardiac manifestations, can lead us to consider this pathology as a differential diagnosis. KEYWORDS: Cardiomyopathy, septal hypertrophy, sudden death, diastolic dysfunction

Sepsis-Induced Suicidal Left Ventricular in a Patient with Hypertrophic Cardiomyopathy/Hypertrophic Obstructive Cardiomyopathy

Hypertrophic cardiomyopathy is the most common heritable cardiomyopathy, manifesting as left ventricular hypertrophy. In this case, a 48-year-male patient presented with complaints of shortness of breath, uneasiness for 15 days, right lower limb pain, and one episode of fever for 2 days. He was initiated on antibiotics but gradually started developing hypotension and oliguria. After optimizing the medical therapy and as a life-saving measure, alcoholic septal ablation was done in this patient as a last resort. The patient was weaned off the ventilator after 72 h and discharged in a stable condition. He has continued follow-up for 8 months and is asymptomatic; the gradient has not recurred. The patient had both issues, and timely alcohol septal ablation helped save the patient by optimizing the hemodynamics. This is a rare situation of suicidal left ventricular induced by sepsis-induced vasodilation.

Pseudo-Conduction in the Mitral Isthmus After Ablation.

A 56-year-old patient with a history of hypertension, dyslipidaemia, and long-standing atrial fibrillation underwent pulmonary vein isolation, endocardial mitral line ablation, and alcohol ablation of the vein of Marshall in 2018. He complained of palpitation due to recurrent atrial flutter, which was poorly controlled by amiodarone. Therefore, catheter ablation was arranged. Pre-ablation echocardiography showed normal left ventricular ejection fraction and computed tomography demonstrated an enlarged coronary sinus (CS).

Alcohol Ablation of Premature Ventricular Complexes Originating from Left Ventricular Summit

Alcohol Ablation of Premature Ventricular Complexes Originating from Left Ventricular Summit

Surgical Management of Aggressive Vertebral Hemangioma

Background: This study includes management of aggressive vertebral hemangioma (VH). VH is the most common primary tumor affecting the vertebral column. In 0.9–1.2% of patients, VH can become symptomatic and is termed as “aggressive vertebral hemangiomas.” They usually require surgery along with adjuvant modalities. Due to its relatively low incidence, there is sparse reporting in the open literature and lack of universal consensus on treatment protocol. We would like to present our institutional experience in managing aggressive VH by surgery along with adjuvant modalities and a comprehensive review of the literature. Materials and Methods: A retrospective review of records of VH cases managed surgically in the past 3 years at our institute was done. All the relevant records and imaging of the patients were retrieved. Results: Five patients were included in the study. All were male with four dorsal and one lumbar lesion. All were treated with surgery along with an adjuvant therapy. Selective arterial embolization was used in one patient, alcohol ablation in three, and vertebroplasty in one. Only one patient had gross total resection, and others had only decompression. Fixation was done in all. All showed good clinical improvement without any complications, except in one. Conclusion: Aggressive VH often requires surgery. Currently, a decompression surgery is preferred due to less morbidity with good clinical outcomes. Various adjuvant therapies have been described in literature to be used perioperatively; yet there is no universal consensus on a standard protocol. Each of them has its own advantages and limitations and thus needs to be carefully selected on an individual basis. Alcohol ablation is an established adjuvant modality, but has to be used with caution.

Myosin Inhibition in Patients With Obstructive Hypertrophic Cardiomyopathy Referred for Septal Reduction Therapy

BackgroundSeptal reduction therapy (SRT), surgical myectomy or alcohol ablation, is recommended for obstructive hypertrophic cardiomyopathy (oHCM) patients with intractable symptoms despite maximal medical therapy, but is associated with morbidity and mortality. ObjectivesThis study sought to determine whether the oral myosin inhibitor mavacamten enables patients to improve sufficiently to no longer meet guideline criteria or choose to not undergo SRT. MethodsPatients with left ventricular (LV) outflow tract (LVOT) gradient ≥50 mm Hg at rest/provocation who met guideline criteria for SRT were randomized, double blind, to mavacamten, 5 mg daily, or placebo, titrated up to 15 mg based on LVOT gradient and LV ejection fraction. The primary endpoint was the composite of the proportion of patients proceeding with SRT or who remained guideline-eligible after 16 weeks’ treatment. ResultsOne hundred and twelve oHCM patients were enrolled, mean age 60 ± 12 years, 51% men, 93% New York Heart Association (NYHA) functional class III/IV, with a mean post-exercise LVOT gradient of 84 ± 35.8 mm Hg. After 16 weeks, 43 of 56 placebo patients (76.8%) and 10 of 56 mavacamten patients (17.9%) met guideline criteria or underwent SRT, difference (58.9%; 95% CI: 44.0%-73.9%; P < 0.001). Hierarchical testing of secondary outcomes showed significant differences (P < 0.001) favoring mavacamten, mean differences in post-exercise peak LVOT gradient −37.2 mm Hg; ≥1 NYHA functional class improvement 41.1%; improvement in patient-reported outcome 9.4 points; and NT-proBNP and cardiac troponin I between-groups geometric mean ratio 0.33 and 0.53. ConclusionsIn oHCM patients with intractable symptoms, mavacamten significantly reduced the fraction of patients meeting guideline criteria for SRT after 16 weeks. Long-term freedom from SRT remains to be determined. (A Study to Evaluate Mavacamten in Adults With Symptomatic Obstructive HCM Who Are Eligible for Septal Reduction Therapy [VALOR-HCM]; NCT04349072)

Abstract No. 263 Ablative treatment of metastatic cervical lymph nodes in patients with thyroid cancer: a comparison of ethanol ablation and cryoablation

Ethanol ablation (EA) has also been described as a viable treatment option in thyroid cancer (TC) patients with spread to cervical lymph nodes (cLN). While EA has been documented to be safe, the treatment often requires multiple therapies and the difficulty of ensuring alcohol permeates and therefore destroys all of the target tissue is well known. While thermal ablation techniques such as cryoablation have been shown to be more effective than alcohol ablation in other settings, to the authors knowledge no report of thermal ablation in cervical lymph nodes has been reported.

Permanent pacemaker implantation after Alcoholic Septal Ablation: long-term outcomes

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy are often submitted to alcohol septal ablation (ASA). One of the most frequent complications is the complete heart block (CHB), requiring permanent pacemaker (PPM) in variable rates, up to 20% of the patients. The long-term impact of PPM implantation in these patients remains unclear. Objectives This study aims to evaluate the long-term pacemaker dependency in patients with PPM after ASA and to assess the long-term impact of PPM in these patients. Methods In a tertiary center, patients who underwent ASA were retrospectively analyzed. Patients with previous PPM or implantable cardio-defibrillator were excluded. The groups with and without PPM implantation after ASA were compared regarding baseline characteristics, procedure data and outcomes. In the group who implanted PPM, the long-term pacing rates were evaluated. Results Between 2009 and 2020, 109 patients underwent ASA. 97 patients were included in this analysis (68% female, mean age 65.2 years-old). 16 patients (16.5%) required PPM implantation for CHB. In those, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics regarding co-morbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with statistically significant differences in the mean age (70.6y/o in the PPM group versus 64.1y/o) and in the beta-blocker therapy rates previously to the intervention (56% in the PPM group versus 84%). Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692U/L versus 1243U/L, p0.05), without significant differences in the alcohol dose (2.1ml in both groups, p0.33). In the PPM group, the mean pacing rates at 1 month, 1 year and 2 years were 66.6±38.0, 50.4±44.1 and 50.8±42.5, respectively, with 2 patients (12.5%) having 1-5% pacing and none having pacing &amp;lt;1% at 2 years. In the group without PPM, 5 patients (6.2%) required posteriorly PPM implantation during the follow-up. There were no statistically significant differences in the two groups regarding in-hospital mortality, 1 year mortality or 1 year re-hospitalization. Despite a lower mean follow-up period in the PPM group (2.3±1.5 years versus 3.5±2.2 years, p0.05), there were no differences in the groups regarding all-cause mortality, cardiac cause mortality and cardiac cause re-hospitalization, with a statistical tendency to a lower all cause re-hospitalization in the PPM group (19% versus 43%, p0.07). Conclusions The registered pacing rates shows that all devices were adequately implanted. The long-term impact analysis suggests that the outcomes in patients who implant PPM after ASA are non-inferior to those who do not, with a tendency to reduce all cause re-hospitalizations.

PO-635-06 IMPACT OF PRIOR ABLATION STRATEGIES ON PROCEDURE EFFICIENCY AND ABLATION STRATEGY IN REPEAT PROCEDURES FOR ATRIAL FIBRILLATION

Many ablation strategies, such as box isolation and linear ablation, have been proposed to improve outcomes in atrial fibrillation (AF) ablation. While the ablation of non-pulmonary vein (PV) targets has gained considerable traction, whether these strategies should be incorporated at the index procedure remain to be addressed. To examine the correlation between ablation strategies at index procedure and the need for creation of non-PV lesion sets at repeat procedure. Data from patients who underwent a first repeat procedure for AF were prospectively collected between February to September of 2021. Where the history of index procedure was available, procedure characteristics and ablation strategies at repeat procedure were grouped and compared based on ablation strategies at index procedure A total of 343 patients [Paroxysmal (PAF): 209, Persistent(PersAF): 134] were included in this analysis. Patients were grouped into PV, PV+ linear (including posterior wall isolation), and PV+other (including focal, rotor, alcohol ablation, and hybrid procedure) based on ablation strategy at index procedure. Non-PV lesion sets were delivered in 52.6% (n=110) and 76.9% (n=103) of the PAF and PersAF cases at repeat procedure. For PAF, elimination of non-PV triggers at the redo procedure was documented in 47.6%, 94.4%, and 83.3% of the PV, PV+linear, and PV+other group, respectively (P<0.05). For PersAF, 73.1%, 83.3%, and 90.9% of the PV, PV+linear, and PV+other group received lesion sets beyond PV isolation at redo (Table 1). More non-PV lesions were delivered per patient at the repeat procedure in the index PV+linear group. At the end of the redo procedure, sinus rhythm was achieved in a similar (p>0.05) proportion of patients across groups in both PAF and PersAF (Table 1). Incorporation of non-PV lesions at index procedure was associated with a more extensive ablation strategy at subsequent repeat procedures. Although a higher percentage of the patients in the index PV+linear and PV+other groups achieved sinus rhythm at the end of the repeat procedure, it did not appear to correlate with the number of non-PV lesion sets created. A larger randomized study may be warranted to investigate long-term clinical outcomes following extensive ablation at index and repeat ablation.

A rare case of insulinoma presenting with deep vein thrombosis, successfully treated with minimally invasive procedures including microwave ablation.

SummaryTreatment of insulinoma can be challenging, while surgical resection is considered the first line. When surgery is contraindicated or is refused, minimally invasive procedures such as selective arterial embolization, local ablative techniques including alcohol ablation, radiofrequency ablation and microwave ablation are being used of late. The world’s first microwave ablation of insulinoma was performed in 2015, after which there have been only a handful of reported cases. A 78-year-old female presented with painful swelling of the left lower limb. She was drowsy and was previously misdiagnosed as epilepsy when she had similar episodes since 2 years ago. She had hypoglycaemia with high serum insulin and C-peptide, and mildly high adjusted calcium, serum prolactin. MRI did not show pituitary adenoma. Lower limb venous duplex scan showed left lower limb deep vein thrombosis for which she was treated with anticoagulation. CT of the abdomen showed a tumour measuring 1.8 cm, located in the antero-superior aspect of the body of the pancreas, with the superior surface being abutted by the splenic artery and the inferior surface being 3 mm above the pancreatic duct, suggestive of an insulinoma. Selective transcatheter arterial embolization of the pancreatic tumour was attempted but was abandoned due to multiple small feeding arteries. Microwave ablation of the tumour was performed successfully. Since there was a possibility of the ablation being compromised due to the heat sink at the splenic artery, 2 mL of 99% alcohol was injected into the rim of the tumour near the artery. She was subsequently normoglycaemic. She defaulted follow up for repeat imaging of pancreas and screening for MEN1 syndrome due to the impact of the COVID-19 pandemic. Minimally invasive procedures are preferred over surgery in selected patients with insulinoma, out of which microwave ablation could be preferentially recommended due to its efficacy and minimal complications. We report the first case of MWA performed in combination with AA in successfully treating insulinoma to our knowledge. This is also the first reported case of DVT associated with isolated insulinoma prior to intervention, though it is rarely reported in MEN1 syndrome.Learning pointsNovel therapeutic minimally invasive procedures are successful in treating selected cases of insulinoma.Microwave ablation could be recommended preferentially over selective trans-arterial embolization, and radiofrequency ablation in treating insulinoma due to its efficacy and minimal complications.We report the first case of microwave ablation performed in combination with alcohol ablation in successfully treating insulinoma to our knowledge.

Innovations in atrial fibrillation ablation.

Catheter-based ablation to perform pulmonary vein isolation (PVI) has established itself as a mainstay in the rhythm control strategy of atrial fibrillation. This review article aims to provide an overview of recent advances in atrial fibrillation ablation technology. We reviewed the available literature and clinical trials of innovations in atrial fibrillation ablation technologies including ablation catheter designs, alternative energy sources, esophageal protection methods, electroanatomical mapping, and novel ablation targets. Innovative radiofrequency (RF) catheter designs maximize energy delivery while avoiding overheating associated with conventional catheters. Single-shot balloon catheters in the form of cryoballoons, radiofrequency, and laser balloons have proven effective at producing pulmonary vein isolation and improving procedural efficiency and reproducibility. Pulsed field ablation (PFA) is a highly anticipated novel nonthermal energy source under development, which demonstrates selective ablation of the myocardium, producing durable lesions while also minimizing collateral damage. Innovative devices for esophageal protection including esophageal deviation and cooling devices have been developed to reduce esophageal complications. Improved electroanatomical mapping systems are being developed to help identify additional non-pulmonary triggers, which may benefit from ablation, especially with persistent atrial fibrillation. Lastly, the vein of Marshall alcohol ablation has been recently studied as an adjunct therapy for improving outcomes with catheter ablation for persistent atrial fibrillation. Numerous advances have been made in the field of atrial fibrillation ablation in the past decade. While further long-term data is still needed for these novel technologies, they show potential to improve procedural efficacy and safety.

Abstract 11687: Management of Hypertrophic Obstructive Cardiomyopathy Using Septal Coiling

Introduction: Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder associated with dynamic left ventricular outflow tract obstruction (LVOTO). Medical management of HOCM aims at decreasing the outflow tract gradient and improving symptoms. In a subset of patients, septal reduction is necessary to achieve symptomatic relief. Alcohol Septal Ablation (ASA) is an accepted method for septal reduction, though it carries risks of complications including unpredictable ethanol diffusion, complete heart block requiring pacemaker and death. We sought to evaluate septal coil embolization (CE) as another method to achieve hemodynamic improvement in HOCM patients with severe LVOTO. Method: We identified 53 HOCM patients that underwent CE at our institution. Baseline septal thickness and LVOT gradients were measured at rest and with Valsalva during echocardiogram (ECHO) and catheterization. Immediate and 2-6 month follow-up post coiling gradients were measured using both modalities and results were compared to baseline. Septal thickness was compared before and after CE. Paired t-test was used to compare pre and post values. Results: Mean age was 68, range (31-90) years, 60% were females, 5.6% had prior permanent pacemaker (PPM). Invasive mean gradient (MG) at rest was 56.6 mmHg and immediately post CE was 16.5 mmHg with mean difference (MD) of 40 mmHg (95% CI 10.6-22.4) (p&lt;0.01). Invasive MG following PVC was 123 mmHg pre and 34 mmHg post with MD of 79 mmHg (95% CI 65-111) (p&lt;0.01). ECHO MG at rest was 79 mmHg and 35 mmHg on follow up with MD 44 mmHg (95% CI 27-60) (p&lt;0.01). Septal thickness at baseline was 17.4 mm and was 14.6 mm on follow up with average reduction of 2.8 mm (95% CI 1.5-4.1) (p&lt;0.01). Ninety three percent of patients reported class III-IV NYHA symptoms at baseline, compared to 14% on follow up. A total of 4 patients required new PPM placement and 6 patients required recoiling. Conclusion: Our study demonstrated a safe and effective alternative compared to ASA for treatment of severely symptomatic HOCM patients. The use of coils compared to alcohol ablation for septal reduction affords more precise tissue ablation with a concomitant reduction in the need for permanent pacemaker insertion with a similar hemodynamic and symptomatic success rate.

Syndrome of Reversible Cardiogenic Shock and Left Ventricular Ballooning in Obstructive Hypertrophic Cardiomyopathy.

BackgroundCardiogenic shock from most causes has unfavorable prognosis. Hypertrophic cardiomyopathy (HCM) can uncommonly present with apical ballooning and shock in association with sudden development of severe and unrelenting left ventricular (LV) outflow obstruction. Typical HCM phenotypic features of mild septal thickening, outflow gradients, and distinctive mitral abnormalities differentiate these patients from others with Takotsubo syndrome, who have normal mitral valves and no outflow obstruction.Methods and ResultsWe analyzed 8 patients from our 4 HCM centers with obstructive HCM and abrupt presentation of cardiogenic shock with LV ballooning, and 6 cases reported in literature. Of 14 patients, 10 (71%) were women, aged 66±9 years, presenting with acute symptoms: LV ballooning; depressed ejection fraction (25±5%); refractory systemic hypotension; marked LV outflow tract obstruction (peak gradient, 94±28 mm Hg); and elevated troponin, but absence of atherosclerotic coronary disease. Shock was managed with intravenous administration of phenylephrine (n=6), norepinephrine (n=6), β‐blocker (n=7), and vasopressin (n=1). Mechanical circulatory support was required in 8, including intra‐aortic balloon pump (n=4), venoarterial extracorporeal membrane oxygenation (n=3), and Impella and Tandem Heart in 1 each. In refractory shock, urgent relief of obstruction by myectomy was performed in 5, and alcohol ablation in 1. All patients survived their critical illness, with full recovery of systolic function.ConclusionsWhen cardiogenic shock and LV ballooning occur in obstructive HCM, they are marked by distinctive anatomic and physiologic features. Relief of obstruction with targeted pharmacotherapy, mechanical circulatory support, and myectomy, when necessary for refractory shock, may lead to survival and normalization of systolic function.

S2505 EUS Identification and EUS-Guided Alcohol Ablation of Insulinoma in a Patient With Hypoglycemia and Roux-en-Y Gastric Bypass Surgery (RYGBS)

S2505 EUS Identification and EUS-Guided Alcohol Ablation of Insulinoma in a Patient With Hypoglycemia and Roux-en-Y Gastric Bypass Surgery (RYGBS)