Alcohol Therapy for Hypertrophic Cardiomyopathy: Is It Time to Toast?
To the Editor:
We have read with interest the article by Knight et al1 on the new technique of nonsurgical reduction as a therapeutic strategy in patients with hypertrophic obstructive cardiomyopathy (HOCM). We congratulate the authors for obtaining excellent results in their series of 18 patients.
We have used the same technique at our center since early last year in a limited number of patients with excellent immediate reductions in left ventricular outflow tract (LVOT) gradients.23 However, we briefly discuss the course of our patients, highlighting the complications encountered.
Acute results: The authors, in their series of 18 patients, experienced the complication of transient complete heart block in only 4 patients, while a further 5 patients were on a permanent pacemaker before the septal ablation. However, both our patients developed complete heart block requiring implantation of a permanent dual-chamber pacemaker.
Furthermore, the authors did not develop any adverse results concerning the left ventricular performance of any of their patients. However, one of our patients developed recurrent episodes of pulmonary edema that stabilized only after initiation of the dual-chamber pacemaker and that may be related to stunned myocardium.2
Chronic results: Both our patients have completed more than 3 months of follow-up. The first patient has completed over 1 year. They have both been doing very well and remain asymptomatic, and their reductions in LVOT gradients have been maintained long term.
This elegant procedure of alcohol-induced septal infarction can be successfully used to reduce LVOT gradients in patients with HOCM. However, the possible complication of complete heart block requiring pacing and pulmonary edema needs to be borne in mind.
The combination of alcohol-induced septal reduction and dual-chamber pacing may be the best solution.
References
- 1 Knight C, Kurbaan AS, Seggewiss H, Henein M, Gunning M, Harrington D, Fassbender D, Gleichmann U, Sigwart U. Nonsurgical septal reduction for hypertrophic obstructive cardiomyopathy. Circulation.1997; 95:2075–2081.CrossrefMedlineGoogle Scholar
- 2 Bhargava B, Agarwal R, Kaul U, Manchanda SC, Wasir HS. Transcatheter alcohol ablation of the septum in a patient of hypertrophic obstructive cardiomyopathy. Cathet CV Diagn.1997; 41:56–58.CrossrefMedlineGoogle Scholar
- 3 Bahl VK, Chandra S, Chopra AK. Septal coronary artery ablation for hypertrophic obstructive cardiomyopathy. Ind Heart J.1996; 48:701–703.MedlineGoogle Scholar
The letter by Bhargava et al raises an interesting point. The creation of complete AV block through injection of alcohol into one of the major septal branches is a distinct possibility. The reports of complete AV block after nonsurgical septal reduction in hypertrophic obstructive cardiomyopathy are conflicting. One series from the Methodist Hospital in Houston, Tex, describes an incidence of 30% of permanent AV block, but only 5% in the last 20 cases. Similar observations have been made by groups in Germany. It is not clear why there seem to be regional differences in the occurrence of this phenomenon.
Dr Bhargava suggests that nonsurgical septal reduction leading to complete AV block could well be a valid treatment. The combination of alcohol ablation and dual chamber pacing may indeed be the best solution for this disease. The occurrence of conduction abnormalities should be borne in mind when undertaking this procedure, and it is mandatory to place a pacemaker electrode into the right ventricle before injecting alcohol into the septal coronary circulation.
