Septal alcoholization in hypertrophic cardiomyopathy: about 11 cases

Outcomes of septal alcoholization in hypertrophic obstructive cardiomyopathy are not enough studied in all centers. The purpose of this study was to determine the outcomes of septal alcoholization in hypertrophic obstructive cardiomyopathy in our hospital. A retrospective and prospective descriptive study focused on all patients aged at least 18 years treated by alcohol septal ablation between July 2005 and June 2010 in the cardiology unit of Clermont-Ferrand teaching Hospital. The inclusion criteria were, hypertrophic obstructive cardiomyopathy with left ventricular outflow tract obstruction ≥ 50 mmHg, symptomatic despite optimal medical therapy. The clinical, paraclinical data and the results of alcohol ablation were collected from medical records of patients and a telephone conversation with the patients or their physicians. These data were analyzed by EPI info 6.04. Eleven patients with average age of 56.27 ± 15, 83 were included of which 81.8% of men. The main indications of alcohol septal were dyspnea stage NYHA II-IV (45.5%), lipothymia (18.2%) and invalidating angina (18.2%). Main electrocardiographic abnormalities were left ventricular hypertrophy and disorders of repolarization with 72.7% each. Minor conductive disorders were found in 45.5% of the cases. The left ventricular outflow tract obstruction was 98.18 ± 25.93 mmHg before alcohol septal ablation and 18.91 ± 31.97 mmHg after a follow-up of 25.64 ± 21.97 months. The success rate was 81.8%. Conductive disorders (45.5%) required the establishment of a definitive pacemaker in 36.4% of the patients. A cardiac defibrillator was implanted at 27.3%. Septal alcoholization was succesful.


Introduction
The prevalence of Hypertrophic cardiomyopathy (HCM) is between 60 to 170/100.000 habitants [1,2]. According to ultrasound studies it is familial in 55% of cases [3,4]. A quarter (25-30%) of them is obstructive. The main clinical symptoms are diastolic heart failure, severe supraventricular or ventricular rhythm disorders and sudden death which burden the prognosis. This study reports the first five years monocentric experience of Clermont-Ferrand teaching Hospital on alcohol septal ablation. Its purpose is to assess the clinical and paraclinical outcomes of patients after alcohol septal ablation.

Methods
It is a retrospective descriptive study covering the period of July Data analysis: Data were analyzed using EPI info 6.04 software.
The results were expressed as mean ± standard deviation and relative frequency.
Of the ten procedures performed the immediate effectiveness on left intraventricular gradient was 54.5%. In the end it was 81.8% of all candidate patients and 90% of those who have actually benefited from the procedure. These results are consistent with data from the literature reporting that the optimal outcome of septal alcoholization could be expected in several weeks or months, this allowing time for a sufficient ventricular remodeling [10].
A significant reduction of systolic anterior motion and mitral regurgitation was also obtained in 81.8% and 72.8% respectively.
This evolution is typical. The rate of complications requiring permanent pacing has significantly improved (5-10%) along with technology and of the staff experience [8]. On the clinical level, nine of the ten patients who underwent alcoholization have shown a decrease of their symptoms with daily normal physical activity.
Despite an hemodynamic failure the tenth patient experienced a reported in the literature [12].
We report bursts of ventricular tachycardia in three patients (27.3%) with recurrent ventricular tachycardia treated with ATP (9.1%) and two bursts of non-sustained new-onset ventricular tachycardia (18.2%). The VT even non-sustained is an independent factor of poor prognosis of HCM because it is responsible for sudden death [13]. Cases of fibrillation were recorded in our study. The relationship between these rhythm disorders and septal alcoholization is not well established, but it seems that the septal alcoholization does not cause more rhythm disorder due to limited myocardial scar compared to the coronary heart disease infarct and a decrease of QT after septal alcoholization [10, 11]. Apart from septal alcoholization, rhythm disorders are an integral part of HCM manifestations of which they are also a risk factor for sudden death or progression towards heart failure or strokes [7,8,14].