Hypertrophic Cardiomyopathy (HCM) Treatment – Alcohol Septal Ablation

Podcast Transcript

Announcer:
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Samir Kapadia, MD:
Hi, I'm Samir Kapadia, Chairman of Cardiology here at Cleveland Clinic. I'm very excited to talk about hypertrophic cardiomyopathy and alcohol ablation today. To be honest, we started the alcohol ablation when alcohol ablation was first developed by Dr. Sigwart in London. He came in 1998 and I was a young fellow. We started to do alcohol septal ablation with Dr. Tuzcu.

Samir Kapadia, MD:
What this alcohol ablation is that when you have hypertrophic cardiomyopathy, the septum, the initial part of the heart where the blood comes out of the left ventricle into the aorta, is larger. What it does is it obstructs the plug as it comes out of the heart and is ejected in the aorta. So this obstruction can be relieved by one of the two mechanisms, or three mechanisms. One is that if you give medications so that the heart does not contract so vigorously, so that obstruction is not felt, or you have surgery where you remove the part of the septum, so that now the blood can flow freely from the left ventricle into the aorta, or you do alcohol septal ablation.

Samir Kapadia, MD:
What the septal ablation is that there are small blood vessels that take blood to the heart and in the septum, there are small blood vessels. So if you identify the appropriate size of the blood vessel and if the septum is thick, you can go inside and inject a little bit of alcohol. So that creates a small heart attack, which is very focal, very localized in that part of the septum, such that it becomes scarred and it is likely removing that part of the septum using alcohol from the, which is injected from the wrist with catheters. So it avoids open heart surgery and you can place it correctly in the right spot so that you can have less obstruction.

Samir Kapadia, MD:
Now, alcohol septal ablation is done mostly in the patients who are at high risk of surgery, because as you can imagine, when we inject alcohol in the septal perforator, the heart attack that happens, or the scar tissue that forms, is dependent on the anatomy of the small blood vessel. So it is not as controlled and as well planned as you will do with open surgery where you can remove as much as the tissue as you want without damaging the rest of the tissue. So this is very similar to surgery, but it is not as precise. So in younger people who can tolerate surgery well, we normally recommend open-heart surgery to remove this part of the muscle. Whereas if patients are high risk for surgery, then this provides a very useful alternative to open heart surgery.

Samir Kapadia, MD:
Now, this is a team approach. So we have experts dealing with hypertrophic cardiomyopathy who are outstanding in terms of deciding when to intervene, whether the medication itself would work or whether people would need alcohol ablation, or they will need open heart surgery. It's also important to recognize that it requires follow-up, genetic testing, arrhythmia management, meaning that you may need an ICD or other things. All of these things can be accomplished by a good team. And this is where we do very well at Cleveland Clinic, where we have very entrusted and thought leaders in the field of hypertrophic cardiomyopathy.

Samir Kapadia, MD:
We did several studies here in Cleveland Clinic and we also published several articles comparing alcohol septal ablation to surgical myectomy. However, when you compare these things, they are not done in the same patient. They are similar patients, but not the exact same kind. Because as I mentioned, younger patients, we typically send them to surgery and in older patients, we do alcohol septal ablation. The idea of comparison is to say that, can we achieve similar results? Yes, we can reduce the gradient, meaning the obstruction, but it is not as good as with very good surgery. Again, the surgery has to be done by the expert surgeons, because if you look at the surgery in different parts of the world, the surgical outcomes are not the same. Very few surgeons do this routinely in a large number. So if you are willing to have this surgery, you need an experienced surgeon who has been doing myectomy for a long time in large number of patients, because it is an artistic surgery. The outcomes, whether you need a pacemaker or not, is also different after alcohol septal ablation and with myectomy. Because when you inject alcohol, you sometimes also damage the conduction system, the wiring of the heart. Again, this is not a negative thing because many times people do require pacemaker even to treat hypertrophic cardiomyopathy.

Samir Kapadia, MD:
And the other thing is that we decide this based on the anatomy, based on the ECG findings. So this is a very involved decision to make sure that the alcohol septal ablation is done in an appropriate patient and in an appropriate way. Very interestingly now the alcohol septal ablation is done all over the country, including in Cleveland Clinic, but we have outstanding outcomes with alcohol septal ablation. We have not had in hypertrophic cardiomyopathy patients any serious events after doing alcohol ablations in several years. I would say that whether you need alcohol septal ablation or you need surgery, has to be determined by an experienced team that deals with hypertrophic cardiomyopathy on a routine basis, and what expert at knowing the literature, as well as the anatomy of the heart. Thank you.

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