INTRODUCTION AND SALIENT FEATURES:

Transcription

1 Price : ` 5/- Honorary Editor : Dr. Milan Chag From e desk of Honorary Editor: Percutaneous Transluminal myocardial septal ablation (PTSMA) has emerged as a less invasive treatment of symptomatic patients wi hypertrophic obstructive cardiomyopay (HOCM). In e past decade, e availability of is sophisticated technique has revived e interest of cardiologists in left ventricular outflow tract obstruction, which has led to e recognition at most patients wi hypertrophic cardiomyopay (HCM) have e obstructive type. Follow-up studies have already shown e safety and efficacy of e procedure, which offers symptomatic relief in most patients. Long-term survival is comparable to historical reports after surgical myectomy. Complications are rare and can be furer reduced by an increase in e experience of e operators, while e eoretical concern for possible ventricular arrhymogenicity caused by e myocardial scar has not been documented by e existing data. Alough ere are still no randomised trials, percutaneous septal ablation is a viable alternative for patients wi HOCM. We have one of e largest series of such erapy in India (Table-4). - Dr. Milan Chag HYPETOPHIC OBSTUCTIVE CADIOMYOPATHY: ALCOHOL SEPTAL ABLATION- A POVEN THEAPY NOW! Figure-1 Figure-2 INTODUCTION AND SALIENT FEATUES: u Hypertrophic cardiomyopay (HCM) is a primary myocardial disorder which is clinically defined by e presence of unexplained left v e n t r i c u l a r h y p e r t r o p h y (Figure-1 & 2). Septum LV u It is inherited as an autosomal dominant trait wi variable penetrance, most commonly involving sarcomeric protein mutations. u The most common genetic cardiac disease, affecting 1 in 500 individuals. u The disease can be diagnosed in patients of all ages and presents as asymptomatic individual to patients wi severe symptoms of exertional dyspnoea or angina and reduced exercise capacity. u The natural history of e disease may be highly heterogeneous wi life expectancy ranging from normal longevity to sudden arrhymic dea (Table 1), often presenting at a young age, or evolution to congestive heart failure or stroke. u M o s t p a t i e n t s p r e s e n t a characteristic left ventricular morphology wi hypertrophy of e basal interventricular septum at is coupled wi systolic anterior motion (SAM) of e anterior mitral Cardiologists Cardiooracic & Vascular Surgeons Cardiac Anaesetists Dr. Ajay Naik (M) Dr. Milan Chag (M) Dr. Dhiren Shah (M) Dr. Niren Bhavsar (M) Dr. Satya Gupta (M) Dr. Urmil Shah (M) Dr. Dhaval Naik (M) Dr. Hiren Dholakia (M) Dr. Vineet Sankhla (M) Dr. Hemang Baxi (M) Dr. Dipesh Shah (M) Dr. Chintan She (M) Dr. Gunvant Patel (M) Dr. Anish Chandarana (M) Pediatric & Structural Surgeons Neonatologist and Pediatric Intensivist Dr. Keyur Parikh (M) Dr. Shaunak Shah (M) Dr. Amit Chitaliya (M) Pediatric Cardiologists Vascular & Endovascular Surgeon Cardiac Electrophysiologist Dr. Kashyap She (M) Dr. Milan Chag (M) Dr. Srujal Shah (M) Dr. Ajay Naik (M)

2 Table-1 isk Factors For Sudden Cardiac Dea 1. Familial sudden dea 2. Unexplained syncope 3. Multiple, repetitive NSVT (Holter) 4. Abnormal exercise response 5. Massive LVH (Septal ickness > 30 mm) 6. Cardiac arrest survivors 7. Documented sustained ventricular tachycardia valve leaflet and leads to dynamic left ventricular outflow tract (LVOT) obstruction and mitral regurgitation due to malcoaptation of e mitral leaflets. u Symptomatic status depends on left ventricular obstruction, diastolic dysfunction and myocardial ischaemia. The existence of significant obstruction at rest or after provocation is associated wi symptomatic status and has significant prognostic implications. (Figure-3) Figure-3 MANAGEMENT: u In general, treatment of patients wi hypertrophic cardiomyopay aims at relieving symptoms, an infarction limited to e part of reducing e risk of sudden dea e septum, eier basal or midc a v i t a r y, i n v o l v e d i n t h e and offering genetic counselling. u Consequently, treatment of development of LV obstruction sy m p t o m a t i c p a t i e n t s w i t h (Table-2). obstructive HCM (HOCM) aims at Figure-4 e reduction of e pressure gradient. Medical treatment wi ß- b l o c ke r s, d i s o p y r a m i d e o r verapamil, however, fails to relieve symptoms in a substantial subset of patients. u In such drug-refractory patients, a l c o h o l s e p t a l a b l a t i o n (Percutaneous Transluminal Septal POCEDUE (PTSMA) Myocardial Ablation-PTSMA) u Under local anesesia and (Figure-4) has come forward as a less prophylactic transjugular temporary invasive treatment an surgery to pacemaker lead insertion, first reduce LVOT obstruction by creating septal artery is identified and OTW Table-2 : INDICATIONS FO SEPTAL EDUCTION (PTSMA) TEATMENT: CLINICAL INDICATION u Symptomatic patients q Drug-refractory or severe side effects of drugs q Functional class III and IV or functional class II wi objective exercise limitations q ecurrent exercise-induced syncope u Failure of prior myectomy or pacemaker u Comorbidity-related increased surgical risk HAEMODYNAMIC INDICATION u Intracavitary gradient >30 mmhg at rest and/or u Provocable gradient >60 mmhg MOPHOLOGIC INDICATION u Echocardiography q Subaortic, SAM-associated gradient q Mid-cavitary gradient q Exclusion of intrinsic mitral valve apparatus disorders u Coronary angiography q Suitable septal branch 2

3 balloon caeter of appropriate size Figure-6 : Procedure (PTSMA) is placed over e guide wire in e artery to occlude it completely. After confirming e target septal tissue by contrast echocardiography, 1 to 3 ml of absolute alcohol (1 ml/ 1 cm of IVS) is injected in target septal artery rough central lumen of OTW balloon caeter under continuous ECG and hemodynamic Figure-7 monitoring. At e end, balloon Pre-PTSMA Post-PTSMA cat h ete r i s re m ove d, c h e c k angiogram is done and patient is monitored in CCU for 48 hours. (Figure-5, 6) Figure-5 : Procedure (PTSMA) Figure-8 Figure-9 PATHOPHYSIOLOGICAL EFFECTS OF SEPTAL ABLATION: u Injection of alcohol during alcohol ablation causes coagulative necrosis of e myocardium and e septal arteries. u Tissue oedema appears early in is process, while muscle replacement 3

4 by scar formation develops only after several days. u Thinning of e ablated area and scar formation lead to a permanent and significant reduction of e obstruction and e associated mitral regurgitation wiin e next 3-12 mons. CLINICAL ESULTS u Haemodynamic success wi reduction in bo resting and p r o v o c a b l e g r a d i e n t s i s accomplished in 90% of patients and is associated wi significant i m p r o v e m e n t i n s y m p t o m s (Figure-7, 8). u Mean NYHA class decreased from 2.9 to 1.2 and mean CCS class decreased from 1.9 to 0.4 at 1-year follow-up. Exercise capacity also improved on a treadmill from to seconds. In a cohort of e first 100 consecutive patients treated e overall survival was 96% Table-3 : Comparison of Septal Myectomy and Percutaneous Alcohol Septal Ablation Parameter Percutaneous Alcohol Septal Ablation Surgical Myectomy Invasiveness Percutaneous groin access Sternotomy Onset of reduction in LVOT Some decrease in gradient instantly, Instantaneous gradient but 6-12 mons for full effect Success rate (%) >80 >95 Procedural mortality (%) ecovery time 2-4 days 1 week Effect on LVOT gradient Decreases to <25 mm Hg Decreases to <10 mm Hg Postprocedure conduction ight bundle branch block Left bundle branch abnormality block Need for permanent 5-10% 3-10 pacemaker-all patients (%) Need for permanent 5% 2% pacemaker if no preexisting conduction abnormalities (%) Leng of follow-up (year) at 8 years, while 74% of patients remained free of severe symptoms, atrial fibrillation, and stroke or ICD implantation. esults of last 12 years are comparable to published literature (Table-3, Figure-9) CONCLUSIONS Alcohol septal ablation has emerged in e last 15 years as a less invasive alternative to e standard surgical treatment of symptomatic patients wi HOCM. The accumulated long-term results have shown an ongoing relief of symptoms in e majority of patients. Hospital mortality can be practically eliminated in experienced centers, while e need for permanent pacing has also been reduced wi increased experience. Table-4 : esults STUDY NO. OF AGE PACEMAKE MEN IN-HOSPITAL LONG-TEM EDO MYECTOMY SUVIVAL SUVIVAL PATIENTS (YEAS) IN-HOSPITAL FOLLOW-UP MOTALITY ALL-CAUSE POCEDUES (%) WITHOUT (%) TIME (YEAS) (%) MOTALITY (%) (%) SYMPTOMS Seggewiss ± ± %@8y 74 % Welge ± ± % 74 % Sorajja ± ± %@4y 76.4 % Kuhn ± % Fernandes ± ± %@8y Kwon ± ± %@10y Nosewory ± % Ten Cate ± ± % Lyne ± %@10y Chag MC ±12 1/ % 80 % 4

5 10 19 Year of Academics C I M S E - C O N 2014 Education For Innovation January 10-12, 2014 Organized by E Care Institute Medical Society for esearch and Education in association wi American Association of Physicians of Indian Origin (AAPI) C Due to an unprecedented response and over booking, registration fees for E-CON 2014 will be non refundable after August 31, I M S E - C O N TACKS - DAY-1 (January 10, 2014) CADIOLOGY TACK Session Directors u Introduction Session Dr. Milan Chag / Dr. Keyur Parikh u Coronary Artery Disease / Acute Coronary Syndromes Dr. Milan Chag / Dr. Keyur Parikh u Plenary Lectures by International Speakers u Hypertension / Lipids & Cardiovascular isk Management u Medical Devices in Cardiology / Interventional Cardiology u Debates u Special Topics Dr. Milan Chag / Dr. Keyur Parikh Dr. Urmil Shah / Dr. Hemang Baxi Dr. Keyur Parikh / Dr. Anish Chandarana Dr. Anish Chandarana Dr. Vineet Sankhla Satellite Sessions (Time : 8.00 pm pm) u Pharmacology & Therapeutics - 1 & 2 u Cardiology Guidelines u Peripheral/ Endovascular /Diabetic Foot u Stroke Dr. Milan Chag / Dr. Hemang Baxi Dr. Urmil Shah / Dr. Satya Gupta Dr. Hemang Baxi / Dr. Srujal Shah Dr. Anish Chandarana / Dr. Vineet Sankhla 5

6 C I M S E - C O N TACKS - DAY-2 (January 11, 2014) CADIOLOGY TACK Session Directors u Interactive ECGs/Arrhymia Dr. Ajay Naik u Atrial Fibrillation/ Arrhymia Dr. Ajay Naik / Dr. Vineet Sankhla u Plenary Lectures Dr. Milan Chag / Dr. Keyur Parikh/Dr. Ajay Naik u E-Oration Dr. Keyur Parikh / Dr. Milan Chag u Congenital Disease / Structural Dr. Milan Chag / Dr. Satya Gupta u Failure Dr. Ajay Naik / Dr. Urmil Shah u Live Case Session All Cardiologists CADIOVASCULA THOACIC SUGEY (CVTS) TACK NEONATAL & PEDIATIC CITICAL CAE TACK CITICAL CAE & PULMONAY TACK Dr. Dhiren Shah / Dr. Dhaval Naik / Dr. Srujal Shah Dr. Amit Chitaliya Dr. Bhagyesh Shah / Dr. Vipul Thakkar /Dr. Harshal Thaker/ Dr. Dhanashri Atre Singh / Dr. Nitesh Shah / Dr. Amit Patel/ Dr. Pranav Modi TOTAL KNEE EPLACEMENT (TK) TACK Dr. Hemang Ambani / Dr. Chirag Patel / Dr. Amir Sanghavi / Dr. Ateet Sharma C I M S E - C O N TACKS - DAY-3 (January 12, 2014) Session Directors CLINICAL CADIOLOGY TACK " " CADIOVASCULA THOACIC SUGEY (CVTS) TACK " " NEONATAL & PEDIATIC CITICAL CAE TACK " " CITICAL CAE & PULMONAY TACK " " TOTAL KNEE EPLACEMENT (TK) TACK " " INTENAL MEDICINE TACK Dr. Milan Chag / Dr. Keyur Parikh TAUMA CAE TACK Dr. Sanjay Shah 6

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