1. Alcohol Septal Ablation: Tips for Success
Tuesday February 21 , 2017
2:50 PM
John S Douglas Jr MD FACC FSCAI
Professor of Medicine
Emory University School of Medicine

2. Disclosure Information
Alcohol Septal Ablation : Tips for Success
Speaker Name John S Douglas Jr MD
I have no disclosures related to this presentation
Off label use of products will be discussed in this presentation.

3. Patient Selection is the 1st Key to Success
Disabling drug-refractory symptoms
Favorable echo findings
- LVOT gradient > 50 mm Hg
- Basal septal hypertrophy
- SAM-septal mitral contact
Avoid mid-ventricular obstruction , subvalvular membranes ,and anomalous chordae
Moderately severe post-lat MR is OK

4. A Simple Procedural Strategy is the 2nd Key to Success
Use myocardial contrast imaging to select the best septal perforator ; the target is the septal perforator supplying the SAM-septal contact point
Moniter the gradient reduction to determine when you are finished

5. Tip #1 :Septal Perforator Selection
With very large septal , subselective injection is frequently the best option
2009 ACC

6. Tip #1 :Septal Perforator Selection
With very large septal , subselective injection is frequently the best option
Baseline Echo
Myocardial Contrast

7. Tip #1 :Septal Perforator Selection
With very large septal , subselective injection is frequently the best option
2009 ACC
Initial LVOF Gradient 100 mm Hg

8. Tip #1 :Septal Perforator Selection
With very large septal , subselective injection is frequently the best option
Following 2cc Alcohol LVOF Gradient 11 mm

9. Tip #2 :Septal Perforator Selection
Small or even “invisible” septals may be usable (hydrophilic wire mm balloon )
Mize

10. Tip #2 :Septal Perforator Selection
Small or even “invisible” septals may be usable (hydrophilic wires balloon )
Myocardial Contrast at SAM-septal Contact Point

11. Tip #2 :Septal Perforator Selection
Small or even “invisible” septals may be usable (hydrophilic wire mm balloon ) 2
LVOF gradient was reduced from 75 to 8 mm

12. Tip #3 :Septal Perforator Selection
Septals arising from a diagonal branch commonly supply the SAM-septal contact point
From tape

13. Tip #3 :Septal Perforator Selection
Septals arising from a diagonal branch commonly supply the SAM-septal contact point
Balloon in Septal Arising From LAD

14. Tip #3 :Septal Perforator Selection
Contrast mixture injected in LAD septal
Right Sided Septal Brightening

15. Tip #3 :Septal Perforator Selection
The diagonal septal was then injected
Balloon now in septal arising from diagonal

16. Tip #3 :Septal Perforator Selection
Contrast echocardiogram after injecting the septal artery arising from the diagonal branch
Left Sided Septal Brightening at SAM-Septal Contact Point

17. Tip #3 :Septal Perforator Selection
Septals arising from diagonals commonly supply the SAM-septal contact point
From tape
Baseline
Post-ablation

18. Tip #4 :Septal Perforator Selection
Not all septals arising from a diagonal branch supply the SAM-septal contact point
From tape
RAO cranial
LAO caudal

19. Tip #4 :Septal Perforator Selection
Not all septals arising from diagonals supply the SAM-septal contact point
From tape
LAO caudal
Guidewire inserted

20. Tip #4 :Septal Perforator Selection
Not all septals arising from a diagonal branch supply the SAM-septal contact point
James McLemore
Baseline
Papillary Muscle Inhancement

21. Tip #4 :Septal Perforator Selection
Not all septals arising from a diagonal branch supply the SAM-septal contact point
From tape
RAO cranial
Balloon in LAD septal

22. Tip #4 :Septal Perforator Selection
Contrast echocardiogram after injection of a septal artery arising from the LAD
Alcohol 2cc in septal from LAD
Valsalva LVOF gradient reduced from 100 to 13mm

23. Tip #4 :Septal Perforator Selection
Not all septals arising from a diagonal branch supply the SAM-septal contact point – results after injecting septal from LAD
James McLemore 5/12/10
Post Alcohol Valsalva Gradient 13mm Hg

24. Tip #5 :Septal Perforator Selection
Septals from ramus intermedius may supply the SAM-septal contact point
Donald Featherstone 5/19/10
RAO Caudal View

25. Tip #5 :Septal Perforator Selection
Septals from ramus intermedius may supply the SAM-septal contact point
Featherstone
RAO Caudal
LAO Caudal

26. Tip #5 :Septal Perforator Selection
Septals from ramus intermedius may supply the SAM-septal contact point
Featherstone
From tape
LAO caudal
Guidewire introduced

27. Tip #5 :Septal Perforator Selection
Septals from ramus intermedius may supply the SAM-septal contact point
Featherstone
Agitated contrast/saline mixture injected
Balloon positioned RAO caudal view

28. Tip #5 :Septal Perforator Selection
Septals from ramus intermedius may supply the SAM-septal contact point
Featherston 5/19/10 A
Baseline Echo
Enhancement at SAM-septal Contact Point

29. Tip #5 :Septal Perforator Selection
Septals from ramus intermedius may supply the SAM-septal contact point
Featherstone
Featherstone
After 2.5cc alcohol no LVOF gradient and occluded septal from ramus
Baseline

30. Tip #5 :Septal Perforator Selection
Septals from ramus intermedius may supply the SAM-septal contact point
Need Donald Featherston echo from 5/19/10 showing septal brightening and gradients and pressure gradients from cath lab if available
LVOF Gradient Reduced to Zero ( 12mm with TNG ) From Resting Gradient of 100 mm Hg

31. Tip #6 :Septal Perforator Treatment
Treatment of more than one septal may be necessary to lower LVOT gradient
Blackshear 7/27/10
57yo Male with 85 mm resting LVOT gradient , 2.3cm septum , disabling symptoms

32. Tip #6 :Septal Perforator Treatment
Treatment of more than one septal may be necessary to lower LVOT gradient
Blackshear 7/27/10
Resting LVOF Gradient 85mm Hg ,Increased to 115 mm Hg Following PVC

33. Tip #6 :Septal Perforator Treatment
Treatment of more than one septal may be necessary to lower LVOT gradient
Willie Blackshear 7/27/10
RAO caudal view
LAO caudal view
1st Septal Perforator Indicated by Arrow

34. Tip #6 :Septal Perforator Treatment
Treatment of more than one septal may be necessary to lower LVOT gradient
Willie Blackshear 7/27/10
RAO caudal unable to wire 1st SP
RAO cranial wired 2nd SP
RAO cranial; contrast injected

35. Tip #6 :Septal Perforator Treatment
Treatment of more than one septal may be necessary to lower LVOT gradient
Blackshear 7/27/10
Myocardial Contrast
Following 2.5 cc alcohol , a 48mm LVOT gradient remained

36. Tip #6 :Septal Perforator Treatment
Treatment of more than one septal may be necessary to lower LVOF gradient
Blackshear 7/27/10
Successful wiring of 1st septal which arises from diagonal
RAO caudal – note absent 2nd septal perforator

37. Tip #6 :Septal Perforator Treatment
Treatment of more than one septal may be necessary to lower LVOF gradient
Blackshear 7/27/10
Following 2cc alcohol in 1st septal
Zero resting and 10mm post-PVC LVOF gradient

38. Tip #7 :Septal Perforator Wiring
Try to avoid use of blocking balloons and Venture catheters ; artery straightening better

39. Tip #7 :Septal Perforator Wiring
Try to avoid use of blocking balloons and Venture catheters ; artery straightening safer

40. Tip #7 :Septal Perforator Wiring
Try to avoid use of blocking balloons and Venture catheters ; artery straightening safer
LAO cranial view

41. Tip #7 :Septal Perforator Wiring
Try to avoid use of blocking balloons and Venture catheters ; artery straightening safer

42. Tip #7 :Septal Perforator Wiring
Try to avoid use of blocking balloons and Venture catheters ; artery straightening safer
Stiff wire placed in LAD
Septal easily wired

43. Tip #7 :Septal Perforator Wiring
Try to avoid use of blocking balloons and Venture catheters ; artery straightening safer
90mm initial gradient reduced to 10mm
Alcohol infused

44. Tip #8 : Alcohol Spillage
Balloon sizing is critical : too small allows retrograde escape ; too large encourages “ melon seeding “ . Frequent monitering of balloon position essential .

45. Tip #8 : Alcohol Spillage
Example of “melon seeding” of balloon resulting in spillage of alcohol and vessel occlusion

46. Tip #9 : Selecting Views to Work In
LAO cranial and caudal views are frequently helpful adjunctive views for wiring difficult septals
LAO Cranial
LAO Caudal

47. Tip #10 : Monitering LVOF Gradient
Consider placing pressure wire in LV in select circumstances to moniter LVOF gradient continously : mild-moderate aortic stenosis , poor echo windows , and to avoid bi-arterial access

48. In Conclusion
Treatment of drug-refractory HOCM with alcohol ablation is a superb therapy which continues to evolve
Successful and optimal application requires extreme attention to detail

49. THANK YOU