Alcohol Septal Ablation

Hypertrophic cardiomyopathy (HCM) is a genetic disorder in which the heart walls are abnormally thick. In HCM, not enough blood can fill the heart and therefore not enough can be pumped around the body. CDC is found in 1 in 500 people in the population; however, most patients are unaware that they have the condition. The diagnosis is made by ECHO (echocardiography; ultrasound of the heart).

Hipertrofik kardiyomiyomati

What is alcohol septal ablation?

What is alcohol septal ablation? This creates a serious obstacle (obstruction) to the outflow of blood. This type of thickening, called obstructive HCM, can be thinned by surgery or non-surgical methods. In septal myectomy, part of the thickened area is cut out. In the non-surgical method called alcohol septal ablation, pure alcohol is given directly to the thickened area to damage it. With the toxic effect of alcohol, the tissues in that area die and start to thin over time. Thus, the patient’s complaints decrease; quality and duration of life increase. Today, alcohol septal ablation is performed in 9 out of every 10 patients requiring thinning of the thickened area and surgery is performed in 1 out of every 10 patients.

Septal miyektomi ameliyatı
Ameliyat: Septal miyektomi (Tufts Medical Center web sitesinden alıntılanarak yeniden düzenlenmiştir.)
Alkol septal ablasyon
Ameliyatsız yöntem: Alkol septal ablasyon (Tufts Medical Center web sitesinden alıntılanarak yeniden düzenlenmiştir.)

To whom is alcohol septal ablation performed?

If there is a thickening of the outflow tract, the first option in treatment is to prevent narrowing of the outflow tract by partially suppressing the contractile force of the heart with medication. In this way, complaints disappear in most patients. Alcohol septal ablation or surgery is performed in patients with obstructive HCM whose symptoms do not improve despite medication. Which patient is more suitable for alcohol septal ablation and which patient is more suitable for surgery is a technical issue and medical details are not included in this article. In non-obstructive (non-obstructive) HCM, alcohol septal ablation or surgery has no place because there is no stenosis in the outflow tract of the heart.

What examinations are performed before the procedure?

  • Blood test: to check for anaemia, kidney failure and other diseases such as infection.
  • ECG To find out if there is a rhythm disturbance in the heart.
  • ECHO (ultrasound of the heart): To determine whether there is thickening of the left ventricular outflow tract, the degree of stenosis, if any, and whether there are additional problems that can only be solved by surgery (e.g. anatomical defects in the mitral valve).

How is alcohol septal ablation performed?

In this procedure, the vessel supplying the thick area at the exit of the heart is identified by angiography and pure alcohol is injected into it. Since alcohol is toxic, it immediately destroys the tissues to which the blood vessel supplies blood. In other words, a heart attack is deliberately induced in that area. Since this small area of the heart loses its vitality, cannot contract and will become thinner in a few months, the outflow tract is enlarged and the obstacle to pumping blood is removed.

The heart continues to function throughout the alcohol septal ablation procedure; unlike surgery, the heart is not stopped. During the procedure, a long, flexible tube (catheter) is inserted into the heart through the groin (leg) vein. A special dye called contrast dye is then injected through the catheter to visualise the heart’s own blood vessels (coronary arteries). This determines which of the heart vessels is the vessel of the thicker area in the outflow tract. A wire and balloon are then inserted through a catheter into the area where the alcohol is to be administered. The balloon is inflated to trap the alcohol in the area to be thinned and prevent it from escaping to other areas of the heart, and then the alcohol is slowly administered through the tip of the balloon. After waiting for 10-15 minutes, the balloon is deflated. Then, the new image of the vessel is taken by dyeing again. In a successful procedure, angiography shows that the vessel is no longer filled with dye and ECHO shows a positive change in the pressure in the outflow tract of the heart.

How long does the procedure take?

Usually, it takes 1 hour. Each patient is different and this time may be shorter or longer.

Is there any pain during or after the procedure?

The patient is awake throughout the procedure. Since the procedure causes a voluntary heart attack in the outflow tract of the heart, strong painkillers and tranquillisers are administered intravenously so that the patient can complete the procedure without chest pain. However, when the patient wakes up, he/she may feel a slight pain at the site of intravenous access. In this case, the pain is relieved with simple painkillers.

Who performs alcohol septal ablation?

This procedure is performed by interventional cardiologists with theoretical and practical training. Septal myectomy is performed by cardiac surgeons.

What are the risks of alcohol septal ablation?

Like any interventional procedure, this procedure also has risks and the most important ones are as follows:

  • A permanent pacemaker may be required in 10 out of every 100 patients. More rarely, a shock pacemaker (ICD) may need to be implanted. The mechanism underlying the risk of a pacemaker is the following: Electrical impulses travelling through the heart use the main conduction pathway, which is located at the exit of the left ventricle. This is where the treatment is administered, i.e. where the alcohol is injected. In 90 out of 100 people, the conduction pathway is not affected by alcohol and there is no problem. In the remaining cases, however, this pathway is partially or completely affected and the heart rate slows down. To prevent this, a pacemaker cable is temporarily inserted into the heart via a vein in the neck or leg during the procedure and for 24 hours after the procedure. If the heart rate drops and does not return to normal within a few days, the temporary pacemaker is replaced by a permanent pacemaker.

  • Strokes, death and heart attacks in areas of the heart other than the problem area (LVOT) occur in 1 in 100 people.

I am concerned about these risks, what should I do?

You may be right to be concerned, but remember: These complications are very rare. The important question is whether the procedure is really necessary. If the decision is made in accordance with current scientific data and guidelines, avoiding this procedure means that your symptoms will not go away and you will continue to have a low quality of life.