Alcohol septal ablation: treating hypertrophic cardiomyopathy

The heart is one of the most important organs in the body. However, like any other body part, it can be affected by a number of health conditions. Hypertrophic cardiomyopathy is one such condition, which involves the heart’s muscle mass increasing abnormally, which can have unpleasant consequences. Professor Michael Mahmoudi is here to explain this condition and how it can be treated with alcohol septal ablation.

Hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is an inherited abnormality of the heart muscle in which the heart becomes more muscular than normal. Although the pattern of muscularity is variable, a common variant involves the muscular wall that separates the two main pumping chambers of the heart. This is referred to as septal hypertrophy.

Symptoms

The symptoms of HCM are variable, with some patients experiencing no symptoms, whilst others may develop breathlessness, chest discomfort upon exertion, palpitations, or loss of consciousness. The latter is a worrying sign and would require urgent medical attention.

Treatment options

The treatment modalities that are currently available for HCM include medications, implantation of pacemakers and/or defibrillators, surgical intervention aimed at “debulking” the heart muscle, and alcohol septal ablation. For any given patient with a diagnosis of HCM, the choice of treatment is best made in conjunction within a multidisciplinary cardiology team with expertise in treating HCM, the patient and their relatives. Owing to its genetic nature, all patients with HCM should have their first blood relatives screened for the condition.

What is alcohol septal ablation?

Alcohol septal ablation (ASA) is an effective treatment modality in symptomatic patients with septal HCM. It is reserved for patients who remain symptomatic despite optimal medical therapy and are either unfit to undergo cardiac surgery or simply choose to have ASA instead of cardiac surgery.

Prior to undergoing ASA, patients are met by the cardiology consultant who will be performing the procedure. The purpose of this visit is to provide patients with a thorough explanation of what the procedure entails, the list of potential complications (less than 1% risk of bleeding, bruising, infection, stroke, need for emergency surgery, and less than 10% risk for requirement of a permanent pacemaker) and to answer any questions which the patient or their family may have.

The procedure involves undertaking a coronary angiogram in order to identify the artery that supplies the relevant section of the septum. Once identified, up to 2 ml of alcohol is injected into this artery with the aim of inducing scarring of the relevant section of the septum, thus reducing its muscle mass, improving the flow of blood out of the heart, and ultimately improving the patients symptoms. ASA is usually completed within one hour. Patients are then kept in hospital for up to three days to ensure that they remain well and that they would not require a permanent pacemaker.

What types of heart disease can alcohol septal ablation treat?

Apart from HCM, alcohol is also being used as part of a treatment strategy for to certain rhythm disturbances of the heart and more recently for “renal denervation” in the treatment of hypertension.

What are the benefits of alcohol septal ablation over other treatment options?

The main advantage of alcohol septal ablation is its potential to avoid open heart surgery.

Does hypertrophic cardiomyopathy always require this treatment?

No. It very much depends upon if patients have symptoms or not. If the patient has no symptoms, there is often no need for any specific treatment.

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