Percutaneous Transluminal Septal Myocardial Ablation Research Articles

Usefulness of multi-detector row computed tomography for the management of percutaneous transluminal septal myocardial ablation in patient with hypertrophic obstructive cardiomyopathy

Percutaneous transluminal septal myocardial ablation (PTSMA) has been a useful therapeutic option for medically refractory patients with hypertrophic obstructive cardiomyopathy (HOCM). Multi-detector row computed tomography (MDCT) has enabled the non-invasive detection of coronary arteries. Therefore, we describe here a patient with HOCM who was treated by PTSMA, and the usefulness of MDCT for its greater certainty and safety for the management of PTSMA.

Time-dependent response of both ventricles after septal ablation: Implications for biventricular support after left ventricular assist device placement

An ovine model of septal ablation was studied to elucidate the mechanisms involved in right ventricular failure when commencing left ventricular mechanical assistance. The disruption of ventricular interdependence after acute and chronic septal injury was examined. Twelve sheep underwent percutaneous transluminal septal myocardial ablation using 0.6 mL ethanol. Twelve other sheep underwent a sham procedure. Left ventricular and right ventricular pressure and volume (conductance) response 15 minutes and 4 weeks postinjury were measured. Ultrasonic crystals measured chamber dimensions and wall movement. Areas at risk and infarct zones were quantified. Compared with sham, ablation chronically reduced systolic interventricular septal thickening (18.4% +/- 5.8% vs 7.3% +/- 3.1%; P < .001) and acutely increased right ventricular ejection fraction (37.6% +/- 8.5% vs 69.9% +/- 7.2%; P < .001), preload recruitable stroke work (42.0 +/- 4.4 erg x 10(3) vs 48.7 +/- 2.0 erg x 10(3), P < .001), end-systolic elastance (1.03 +/- 0.19 mm Hg mL(-1) vs 1.31 +/- 0.18 mm Hg mL(-1); P < .001), and Tau (24.9 +/- 3.8 ms vs 29.6 +/- 8.2 ms; P < .001). In contrast, for left ventricular ejection fraction (55.5% +/- 5.9% vs 38.9% +/- 7.7%; P < .001), preload recruitable stroke work (85.9 +/- 10.6 mm Hg vs 66.5 +/- 9.6 mm Hg; P < .001) and elastance (2.13 +/- 0.51 mm Hg mL(-1) vs 1.81 +/- 0.44 mm Hg mL(-1); P < .001) were reduced, but Tau increased (22.0 +/- 3.5 ms vs 28.9 +/- 5.8 ms; P < .001) and remained elevated at 4 weeks compared with sham. The area at risk was the same between groups, and injury was limited to the septum (17.2% +/- 2.7% vs 2.9% +/- 5.8%; P < .001). Acute and chronic hemodynamic responses are distinctly different after septal injury; the acute response demonstrates a paradoxical motion. Resolution of this motion at 4 weeks is suggestive of reduced septal compliance and buttressing. Ventricular interactions after placement of a left ventricular assist device will vary depending on the injury duration.

MR Imaging Evaluation of Regional, Remote, and Global Effects of Percutaneous Transluminal Septal Myocardial Ablation in Hypertrophic Obstructive Cardiomyopathy

To evaluate regional, remote, and global effects of percutaneous transluminal septal myocardial ablation (PTSMA) in hypertrophic obstructive cardiomyopathy (HOCM) using magnetic resonance (MR) imaging. Twenty-one patients with HOCM underwent cine and delayed contrast-enhanced MR imaging. The regional effects of ablated myocardium as well as remote and global effects of PTSMA were assessed. The ablated interventricular septal myocardium was hyperenhanced and thinned after successful PTSMA. Decreases in posterior wall thickness and myocardial mass were observed more than 12 weeks after PTSMA. Decreases in posterior wall thickness, myocardial mass, and left atrial diameter were observed in patients without myocardial hyperenhancement before PTSMA. Neither reduction nor increase in hyperenhancing myocardium, except for the ablated myocardium, was observed after PTSMA. Cardiac MR imaging showed regional, remote, and global effects of PTSMA on the myocardium in HOCM and might indicate patients with a good global response to PTSMA.

Delayed electrocardiographic changes after percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy

Objectives This work aimed to study the delayed electrocardiographic changes, including Q-T interval, corrected Q-T dispersion, and heart rate variability (HRV) 3 years after percutaneous transluminal septal myocardial ablation (PTSMA), in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). Methods In 26 patients (11 women, 15 men; average age, 37.4 ± 11.2 years) with symptomatic and medically refractory HOCM, 1.4 ± 0.5 septal branches were occluded with an injection of 3.8 ± 1.3 mL of alcohol (95%) to ablate the hypertrophied interventricular septum. Baseline and 3 days and 3 years postprocedure 24-hour Holter electrocardiographic findings were determined. Results One patient developed complete atrioventricular block requiring permanent pacing. The PR interval was significantly prolonged 3 days after ablation, but recovered 3 years postprocedure. Three days after the procedure, all patients developed right bundle branch block, which was present in 24 patients after 3 years. The QRS duration was significantly prolonged 3 days after ablation and during 3 years of follow-up. There was significant and persistent prolongation of QT interval and transient prolongation of corrected QT dispersion 3 days after ablation and returned to preablation values 3 years postprocedure, but JT interval and corrected JT dispersion were not significantly changed after PTSMA. Heart rate variability data (time domain and frequency domain) 3 days and 3 years after PTSMA, including low frequency, high frequency, root mean squared successive difference interval, and the percent of sinus cycles differing from the preceding cycle by more than 50 milliseconds, significantly increased compared to that before the procedure. Low frequency/high frequency, SD of all normal-to-normal intervals, and SD of 5-minute average normal-to-normal intervals were not significantly changed after PTSMA. Conclusions Percutaneous transluminal septal myocardial ablation for HOCM induces significant delayed electrocardiographic changes in most patients. The changes include QRS prolongation, new right bundle branch block, persistent QT prolongation, transient QT dispersion and PR prolongation, and changes in HRV data. Electrocardiographic long-term follow-up of a larger series of patients is required to determine the conclusive therapeutic significance.

Quantitative and Qualitative Changes in the Resting Electrocardiograph and Ventricular Conduction after Percutaneous Transluminal Septal Myocardial Ablation

Quantitative and Qualitative Changes in the Resting Electrocardiograph and Ventricular Conduction after Percutaneous Transluminal Septal Myocardial Ablation

Determinants of Peak Cardiac Enzyme Levels after Percutaneous Transluminal Septal Myocardial Ablation for Symptomatic Hypertrophic Cardiomyopathy

Determinants of Peak Cardiac Enzyme Levels after Percutaneous Transluminal Septal Myocardial Ablation for Symptomatic Hypertrophic Cardiomyopathy

Percutaneous Transluminal Septal Myocardial Ablation—A Viable Treatment for Hypertrophic Obstructive Cardiomyopathy? : The MonashHeart Experience

Percutaneous Transluminal Septal Myocardial Ablation—A Viable Treatment for Hypertrophic Obstructive Cardiomyopathy? : The MonashHeart Experience

Percutaneous septal ablation with absorbable gelatin sponge in hypertrophic obstructive cardiomyopathy

The treatment of the hypertrophic obstructive cardiomyopathy (HOCM) by percutaneous transluminal septal myocardial ablation (PTSMA) with ethanol injection has greatly improved in the last years. This report describes the case of a patient with symptomatic drug-refractory HOCM who underwent an unsuccessful attempt to thrombose the septal artery by PTSMA with alcohol. It has therefore been decided to use small absorbant gelatin sponge (AGS) particles, obtaining immediate thrombotic occlusion of the artery and excellent hemodynamic results with immediate and permanent disappearance of the gradient. The patient progressed satisfactorily and displayed lower than average creatine kinase levels in comparison to the rest of our PTMSA patients. After 2 years of follow-up he still remains asymptomatic and without any gradient. These results suggest that PTSMA with AGS could be a valuable alternative treatment of HOCM.

1178 Evaluation of effects of percutaneous transluminal septal myocardial ablation on diastolic function in patients with hypertrophic cardiomyopathy

1178 Evaluation of effects of percutaneous transluminal septal myocardial ablation on diastolic function in patients with hypertrophic cardiomyopathy

Abstract 599: RV Protection Conferred by Chronic Effects of Percutaneous Transluminal Septal Myocardial Ablation During High Level LV Unloading in Sheep

Background: Severe RV failure is common (~25%) following acute LVAD unloading. The role of IVS dysfunction in this response remains uncertain, so we studied chronic ventricular interactions with incremental LV unloading following IVS damage. Methods: Percutaneous transluminal septal myocardial ablation (PTSMA) with ethanol caused irreversible IVS damage in 6 sheep. Main septal artery catheterization was performed in 6 other sham animals, and both groups underwent hemodynamic assessment 4w later. RV volume was derived from a 3-axis ellipsoidal subtraction model using sonomicrometer dimensions. RV- ejection fraction (EF), pressure recruitable stroke work (PRSW), end-systolic elastance (Ees), 1 st derivative of maximum RV pressure (dP/dt), and Tau were derived from P/V loops during IVC occlusion and LV unloading (25/50/75/100%) using a Bio-Medicus pump. Flow-probes measured % steady-state pulmonary, aortic, and mechanical bypass flow. Results: Response to varying LV assist levels is shown in the Figure ( * =P&lt;0.05). RV- EF, PRSW and Ees decreased in shams, but remained stable in PTSMA during high level LV unloading. DP/dt decreased in shams at 75% LV unloading and trended down at 100%. In contrast, high baseline Tau after PTSMA normalized with moderate ≥50% LV assist. Conclusions: Institution of LV unloading in a chronic IVS damaged but otherwise healthy heart protects against compromised RV function, whereas sham animals respond adversely. Chronic IVS fibrosis may confer protection by limiting changes in RV chamber geometry.

Occurrence of de novo sustained monomorphic ventricular tachycardia induced after percutaneous transluminal alcohol septal myocardial ablation for hypertrophic obstructive cardiomyopathy

We report here a 75-year-old male with hypertrophic obstructive cardiomyopathy of de novo sustained monomorphic ventricular tachycardia (VT) after successful percutaneous transluminal alcohol septal myocardial ablation (PTSMA). In this case history, the necrotic induced by the PTSMA procedure might represent a region of slow conduction that is a circuit of re-entry and therefore stimulation might be spread around. Therefore, the basis of the sustained monomorphic VT was thought to be the presence of a focal necrotic area, itself a complication arising from the PTSMA procedures. In conclusion, the PTSMA procedure may have caused a de novo episode of ventricular arrhythmia.

Hypertrophic Obstructive Cardiomyopathy

A 61-year-old man with exertional dyspnea was diagnosed with hypertrophic obstructive cardiomyopathy. The echocardiogram demonstrated an interventricular septum with a thickness of 18 mm, marked systolic anterior motion, and mitral regurgitation grade 3. The left ventricular outflow tract (LVOT) gradient was 100 mm Hg. The patient was treated with percutaneous transluminal septal myocardial alcohol ablation, resulting in a residual LVOT gradient of 20 mm Hg. Mild coronary artery disease of the proximal left anterior descending coronary artery (LAD) and the first diagonal branch (D1) (40% diameter stenosis by quantitative coronary angiography) was left untreated. The patient remained asymptomatic for 6 months and then again had development of exertional dyspnea. The echocardiogram revealed relapse of the LVOT gradient (80 mm Hg). Repeat percutaneous transluminal septal myocardial alcohol …

Myocardial Perfusion After Percutaneous Transluminal Septal Myocardial Ablation as Assessed by Myocardial Contrast Echocardiography in Patients with Hypertrophic Obstructive Cardiomyopathy

Microvascular dysfunction in hypertrophic obstructive cardiomyopathy (HOCM) depends on a complex interplay of functional and anatomic mechanisms. We used myocardial contrast echocardiography in 16 consecutive patients with HOCM (mean age 49 +/- 15 years; 11 men) referred for percutaneous transluminal septal myocardial ablation to assess myocardial perfusion before and 6 months after the procedure. Myocardial contrast echocardiography was performed using real-time imaging during intravenous injection of SonoVue. Myocardial blood velocity (beta) and a semiquantitative assessment of blood volume were obtained in the apical 4-chamber views at midapical septum. Twelve healthy individuals served as control subjects. In patients with HOCM, beta was lower either before (0.17 +/- 0.04 vs 0.50 +/- 0.34 s(-1), P = .006) or after (0.23 +/- 0.07 vs 0.50 +/- 0.34 s(-1), P = .02) successful percutaneous transluminal septal myocardial ablation compared with control subjects. A patchy perfusion pattern was seen in all the patients with HOCM either before or after the procedure. In patients with HOCM percutaneous transluminal septal myocardial ablation improves, but does not normalize microvascular function.

Midterm outcomes of percutaneous transluminal septal myocardial ablation in patients with hypertrophic obstructive cardiomyopathy refractory to medication

Hypertrophic 妨碍的心肌症(HOCM ) 是严重不对称的肥大描绘的基因混乱内部当全身的任何其它或心脏病不在时的室的中隔(IVS ) 。占优势的反常 haemodynamics 被增加的左室的流出道压力坡度( LVOTG )和僧帽形的 valve.1 的反常收缩前面的运动引起“ 2 最近，在那里在把酒精注入左前面的下降动脉的第一根主要氏族的冠的动脉一直在种兴趣(经皮的 transluminalseptal 心肌的脱离， PTSMA )作为在尽管有最佳的药，仍然保持征兆的有 HOCM 的病人的 myectomy 的一种选择包括贝它肾上腺素能的堵住代理人， verapamil ， anddisopyramide 。PTSMA 是由由乙醇注入导致局部性的心肌的梗塞进左前面的下降冠的动脉的氏族的分支组成的一个新过程。结疤并且变瘦 intra 室氏族(IVS ) 导致 LVOT 拓宽，并且因而，压力坡度和征兆的改进减少。最严重的复杂并发症 afterPTSMA 过程是完全的心块(3%—5%) 要求永久心律调整器。Severalresearchers 报导了 15%—完全的正确的捆分支块(CRBBB ) 的 33% 发生。然而， CRBBB 的含意在紧跟的时期期间仍然保持不清楚。在我们在 1999 的开始的工作的 CRBBB 的普通出现导致现在的学习记录长期的临床的重要性 ofCRBBB 追随者 PTSMA 过程。

Comparison of percutaneous transluminal septal myocardial ablation versus septal myectomy for the treatment of patients with hypertrophic obstructive cardiomyopathy—A meta analysis

Background The effects of percutaneous transluminal septal myocardial ablation (PTSMA) with septal myectomy in patients with hypertrophic obstructive cardiomyopathy (HOCM) are not thoroughly compared. Methods Three articles comparing the effects of PTSMA and septal myectomy treatment for HOCM were identified from a search in Pubmed, and a meta analysis was conducted. Results 177 patients (86 underwent PTSMA and 91 underwent septal myectomy) were included. Interventricular septum thickness was decreased from 22.1 to 15.1 mm ( p < 0.05) in PTSMA group and from 22.0 to 13.9 mm ( p < 0.05) in septal myectomy group; left ventricular end-diastolic dimension was increased from 41.8 to 45.2 mm ( p < 0.05) in PTSMA group and from 41.8 to 43.9 mm ( p < 0.05) in septal myectomy group; NYHA class was improved from 3.17 to 1.47 ( p < 0.05) in PTSMA group and from 2.97 to 1.36 ( p < 0.05) in septal myectomy group; there were no differences in the two groups. However, left ventricular outflow tract gradient was decreased from 76.0 to 15.7 mm Hg ( p < 0.05) in PTSMA group and from 74.7 to 9.4 mm Hg ( p < 0.05) in septal myectomy group and the effect of septal myectomy was better than PTSMA ( p < 0.05). Conclusions The effects of septal myectomy treatment for HOCM are better with regard to relief of LVOT gradient, and lower risk of pacemaker requirement, compared to PTSMA. Large randomized clinical trials further comparing the two treatments are suggested.

Intracardiac echocardiography during interventional procedures.

As non-surgical percutaneous interventions are increasingly considered for many cardiac conditions, high quality near field continuous imaging is warranted, in order to optimize the results, and to prevent and detect complications. Transesophageal echocardiography is the standard imaging technique, however general anesthesia and endotracheal intubation is required during prolonged monitoring of percutaneous interventions. Intracardiac echocardiography is a novel emerging tool that allows a view within the cardiac chambers and the large vessels and can be employed by the interventional cardiologist. In our department, a phased array, multi-frequency, four-way steerable catheter (AcuNaV - Siemens) was used for anatomic and haemodynamic cardiac assessment and for guidance and monitoring during non-coronary percutaneous interventions. In total 135 patients underwent intracardiac echocardiographic investigation, 4 during diagnostic heart catheterization, 6 during percutaneous coronary intervention with the use of a new left ventricular assist device, the Impella Recover LP 2.5 system, 26 during percutaneous transluminal septal myocardial ablation (10 patients were reevaluated with intracardiac echocardiography at 6 months), 50 during interatrial communication closure, 4 during percutaneous left atrial appendage transcatheter occlusion, 7 during percutaneous balloon valvuloplasty, 1 during percutaneous aortic valve replacement and 27 during pulmonary vein ablation. All patients tolerated the procedure very well with no catheter related complications. However, there were two complications, which were due to the guidewire and the sheath, an inferior vena cava dissection and a femoral vein dissection, respectively. Phased array intracardiac imaging is a safe technology, which facilitates non-surgical interventions by providing high quality images. It eliminates the need for general anesthesia and thus increases the patient comfort.

Use of percutaneous transluminal septal myocardial ablation for relief of outflow tract obstruction in cardiac amyloidosis: A novel therapeutic target

Cardiac amyloidosis typically presents with diastolic heart failure, but asymmetrical septal hypertrophy with outflow tract obstruction has been described. We illustrate the case of a 71-year-old woman with biopsy-proven cardiac amyloidosis and severe medical comorbidities with refractory severe heart failure who had asymmetric septal hypertrophy, systolic anterior motion (SAM) of the mitral valve, and a resting left ventricular outflow tract gradient of 86 mm Hg, increasing to 102 mm Hg on Valsalva maneuver. She underwent percutaneous transluminal septal myocardial ablation (PTSMA) with a dramatic resolution of her SAM and outflow tract obstruction, confirmed by intracavitary pressure wire measurements. PTSMA is technically feasible in this context, and correction of outflow tract obstruction may represent a new therapeutic target in cardiac amyloidosis.

Paradoxical improvement of phase 4 block by beta adrenoceptor blocking agent in a patient with hypertrophic obstructive cardiomyopathy after percutaneous transluminal septal myocardial ablation

Paradoxical improvement of phase 4 block by beta adrenoceptor blocking agent in a patient with hypertrophic obstructive cardiomyopathy after percutaneous transluminal septal myocardial ablation

An Aneurysmal Formation of a Septal Branch after Percutaneous Septal Myocardial Ablation

A 73-year-old woman presented with transitional syncope that occurred while she was taking a bath. Echocardiography showed asymmetric septal hypertrophy and left ventricular outflow tract pressure gradient (LVOTPG) of 180 mmHg, suggesting hypertrophic obstructive cardiomyopathy-related syncope. LVOTPG was refractory to medications including βblockers, sodium channel blockers and calcium antagonists. Therefore, percutaneous transluminal septal myocardial ablation (PTSMA) was performed. Initial coronary angiography (CAG) showed no significant irregularities (Fig. 1a). After the infusion of 2 ml of 99.5% ethanol at a rate of 0.5 ml/min to the second septal branch, CAG revealed that the branch was not occluded completely. Then we tried to do an additional ablation, and a balloon catheter was inserted into the branch again. To confirm whether an inflated balloon catheter was wedged in the septal branch, we injected contrast medium into it through this catheter. An aneurysmal formation was observed in the branch. Therefore, we discontinued the ablation. CAG also showed the same formation, in which the pooling of contrast medium disappeared for a few seconds (Fig. 1b, arrow). Follow-up CAG at 20 days post-PTSMA revealed enlargement of the aneurysmal formation (Fig. 1c, arrow), although changes in LVOTPG were not observed. Subsequent CAG at 9-months post-PTSMA showed spontaneous disappearance of the aneurysmal formation (Fig. 1d). An aneurysmal formation of the septal branch is a rare complication of PTSMA.

Is Surgery Best for HOCM

Percutaneous transluminal septal myocardial ablation (PTSMA) with injected ethanol is being used increasingly to reduce the left-ventricular outflow