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. 2022 Jul 2;1(5):100396.
doi: 10.1016/j.jscai.2022.100396. eCollection 2022 Sep-Oct.

Safety and Outcomes of Alcohol Septal Ablation Prior to Transcatheter Mitral Valve Replacement

Mohamed Elhadi  1 , Mayra Guerrero  1 , Jeremy D Collins  1 , Charanjit S Rihal  1 , Mackram F Eleid  1
Affiliations

Safety and Outcomes of Alcohol Septal Ablation Prior to Transcatheter Mitral Valve Replacement

Mohamed Elhadi et al. J Soc Cardiovasc Angiogr Interv. .

Abstract

Background: Patients undergoing transcatheter mitral valve replacement (TMVR) for mitral valve disease caused by severe mitral annular calcification are at risk of left ventricular outflow obstruction. Preemptive alcohol septal ablation (ASA) can potentially mitigate the risk of this complication and is well established in patients with hypertrophic obstructive cardiomyopathy (HCM).

Methods: This retrospective study compared procedural characteristics and outcomes in patients who underwent ASA for TMVR vs HCM.

Results: In total, 102 patients were included, 22 in the TMVR group and 80 in the HCM group. Echocardiography demonstrated increased septal wall thickness in the HCM group (19 ​± ​3.1 ​mm vs 12.7 ​± ​2.0 ​mm; P ​< ​.001). The mean volume of ethanol injected was higher in the HCM group (1.4 ​± ​0.49 ​mL vs 0.8 ​± ​0.2 ​mL; P ​< ​.001). The average neo-left ventricular outflow tract area increased significantly after ASA in the patients undergoing TMVR (135 ​± ​89 ​mm2 vs 233 ​± ​111 ​mm2; P ​< ​.001). Six patients in the TMVR group did not achieve an adequate increase in the neo-left ventricular outflow tract area and required further procedures after ASA. The incidence of post-ASA complete heart block requiring a permanent pacemaker tended to be higher in the TMVR group (35% vs 21%; P ​= ​.195). No patients in either group had ventricular arrhythmia or stroke. Major bleeding complications were 4% in the HCM group and 0 in the TMVR group. The 30-day mortality was 4% in the HCM group and 0 in the TMVR group; however, 1 patient died at 37 ​days in the TMVR group, presumably from late heart block.

Conclusions: Preemptive ASA in patients undergoing TMVR demonstrated safety and short-term clinical outcomes similar to patients with HCM.

Keywords: catheter-based coronary and valvular interventions; septal ablation; valvular heart disease.

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Figures

None
Graphical abstract
Figure. 1
Figure. 1
Baseline and post-ASA frame neo-LVOT and skirt neo-LVOT areas. Cardiac computed tomography images with a virtual valve in the mitral position demonstrating a change in the LVOT anatomy after ASA (A-F). Pre-ASA frame neo-LVOT area increased from 50 ​mm2 to 199 ​mm2 after ASA. Pre-ASA skirt neo-LVOT area increased from 205 ​mm2 to 474 ​mm2 after ASA. ASA, alcohol septal ablation; LVOT, left ventricular outflow tract.
Central Illustration
Central Illustration
Safety of alcohol septal ablation for septal reduction prior to transcatheter mitral valve replacement compared to obstructivehypertrophic obstructive cardiomyopathy. (A) Cardiac computed tomography images with virtual valve in the mitral position demonstrating a change in the LVOT anatomy after ASA. (B) The mean septal thickness (in millimeters) was measured on pre-ASA echocardiography and was higher in the HCM group (19.3 ​± ​3.1 ​mm) than in the TMVR group (12.7 ​± ​2 ​mm) ​(P ​< ​.001). (C) The mean volume of alcohol injected during the ASA procedure was also higher in the HCM group (1.4 ​± ​0.49 ​mL) than in the TMVR group (0.8 ​± ​0.2 ​mL) ​(P ​< ​.001). (D) The incidence of complete heart block requiring PPM after ASA was 35% in the TMVR group and 21% in the HCM group (P ​= ​.195). The 30-day mortality was 0 in the TMVR group and 3.8% in the HCM group. ASA, alcohol septal ablation; HCM, hypertrophic obstructive cardiomyopathy; LVOT, left ventricular outflow tract; PPM, permanent pacemaker; TMVR, transcatheter mitral valve replacement.
Figure. 2
Figure. 2
Differences in mean septal thickness and volume of alcohol between the TMVR and HCM groups. (A) The mean septal thickness (in millimeters) was measured on pre-ASA echocardiography and was higher in the HCM group (19.3 ​± ​3.1 ​mm) than in the TMVR group (12.7 ​± ​2 ​mm) ​(P ​< ​.001). (B) The mean volume of alcohol injected during the ASA procedure was also higher in the HCM group (1.4 ​± ​0.49 ​mL) than in the TMVR group (0.8 ​± ​0.2 ​mL) ​(P ​< ​.001). ASA, alcohol septal ablation; HCM, hypertrophic obstructive cardiomyopathy; TMVR, transcatheter mitral valve replacement.
Figure. 3
Figure. 3
Outcomes after alcohol septal ablation: Complete heart block and 30-day mortality. The incidence of complete heart block requiring PPM after alcohol septal ablation was 35% in the TMVR group and 21% in the HCM group (P ​= ​.195). Thirty-day mortality was 0 in the TMVR group and 3.8% in the HCM group. HCM, hypertrophic obstructive cardiomyopathy; PPM, permanent pacemaker; TMVR, transcatheter mitral valve replacement.
Figure. 4
Figure. 4
Survival after alcohol septal ablation. A Kaplan-Meier plot for the estimated 1-year survival after alcohol septal ablation for the TMVR and HCM groups. Cumulative survival was similar between the HCM and TMVR groups (P ​= ​.251). HCM, hypertrophic obstructive cardiomyopathy; TMVR, transcatheter mitral valve replacement.
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