← All decks
Cardiology
Ethanol Septal Ablation
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
9 sections · 101 slides
Overview
- Scope of this presentation
Hypertrophic cardiomyopathy and outflow obstruction
- Definition of hypertrophic cardiomyopathy
- Diagnostic criteria
- Clinical presentation
- Pathophysiology of heart failure symptoms
- Definition of left ventricular outflow tract obstruction
- Mechanism of dynamic outflow obstruction
- Mitral apparatus contributors to obstruction
- Place of septal reduction therapy in management
- Reverse remodeling after relief of obstruction
- Sequence generating the dynamic outflow gradient
History and evolution of the procedure
- Origin of the technique
- Haemodynamic proof of concept
- The first three ablations
- Findings and limitations of the first series
- Knight 1997: early complication data
- Lessons from the early two-centre series
- Faber 1998: the 66-patient German cohort
- Evolution of the procedure
- Long-term outcomes in early registries
- Meta-analysis of the early experience
- Reported procedural complications
- Technical refinements over three decades
- Reduction in ethanol volume and formal training
Contemporary outcomes and real-world experience
- Guideline recommendation
- Evidence base for the comparison with myectomy
- Findings of the 2019 comparative meta-analysis
- Indications favouring surgical myectomy
- Typical profile of the ablation patient
- Ablation at high-volume centres compared with myectomy
- Effect of operator and institutional volume
- Guideline benchmarks for high-volume centres
- Real-world volume gap in the United States
- Training requirements for new operators
Patient selection
- Mechanism of gradient relief after ethanol injection
- Mechanism of sustained benefit after ablation
- Indications for ethanol septal ablation
- Absence of another surgical indication
- Relative contraindications: patient factors
- Relative contraindications: anatomical factors
- Age and sex in the choice of therapy
- Cardiac myosin inhibitors as an alternative
- VALOR-HCM and deferral of septal reduction therapy
- Candidates for myosin inhibitors rather than ablation
- Limitations of myosin inhibitor therapy
- Decision pathway for septal reduction therapy
Preprocedure evaluation
- Transthoracic echocardiography as the first step
- What echocardiography must exclude
- Accuracy of echocardiographic measurement
- Right heart catheterisation in the workup
- Invasive measurement of the outflow gradient
- Simultaneous left ventricular and aortic pressure tracings
- Pitfalls in invasive gradient measurement
- Provocation and sedation during the study
- Coronary angiography for target selection
- Angiographic projections used before septal ablation
- Angiographic projections and what each shows
- Components of the preprocedure assessment
Technique
- Temporary transvenous pacemaker before ablation
- Position of the pacing lead
- Guide catheter selection and stability
- Vascular access and anticoagulation
- Wiring the septal perforator
- Steps of alcohol septal ablation on angiography
- Positioning the over-the-wire balloon
- Septal artery calibre and balloon anchoring
- Confirming occlusion before ethanol
- Selective angiography through the balloon lumen
- Selective injection with simultaneous contrast echocardiography
- Myocardial contrast echocardiography during selection
- Ethanol injection technique
- The five-minute dwell
- Doppler assessment during ablation
- Outflow tract Doppler before and after ablation
- Analgesia during ethanol injection
- Monitoring during and after the injection
- The final angiogram
- Procedural sequence in summary
Postprocedure care and procedural success
- Immediate postprocedure care
- Cardiac enzyme monitoring
- Conduction surveillance after ablation
- Immediate procedural success
- Reassessment at three to six months
- Centre of excellence targets for procedural success
- Conclusion
- Key points to carry away
References
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
- Join our WhatsApp groups