Septal Ablation with Radiofrequency Catheters Guided by Echocardiography for Treatment of Patients with Obstructive
Bruno P Valdigem1, Edileide B Correia1, Dalmo A R Moreira1
1Instituto Dante Pazzanese de Cardiologia,São Paulo, SP - Brasil.
Insights
Transesophageal echocardiography-guided radiofrequency septal ablation effectively reduced left ventricular outflow tract obstruction in hypertrophic cardiomyopathy patients. This safe procedure offered sustained gradient reduction and symptom relief without major complications.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- Hypertrophic cardiomyopathy (HCM) can cause left ventricular outflow tract (LVOT) obstruction, leading to debilitating symptoms.
- Pharmacological treatments may be insufficient for refractory symptoms, necessitating interventions like septal ablation.
- Radiofrequency (RF) catheter septal ablation, guided by electroanatomic mapping, is effective but carries a risk of atrioventricular block.
Purpose of the Study:
- To evaluate the long-term efficacy of transesophageal echocardiography (TEE)-guided septal ablation in relieving ventricular-arterial gradient in HCM patients.
- To assess the impact of TEE-guided septal ablation on functional class and echocardiographic parameters.
- To determine the safety profile of this interventional approach.
Main Methods:
- Twelve patients with drug-refractory LVOT obstruction underwent TEE-guided endocardial septal ablation using RF energy.
- Catheter placement was guided by TEE to target the area of maximal septal obstruction.
- Temperature-controlled RF applications were performed sequentially, with gradient reassessment after each application.
Main Results:
- Mean maximum gradients significantly decreased from 96.8±34.7 mmHg to 62.7±25.4 mmHg at three months (p=0.0036) and to 36.1±23.8 mmHg at one year (p=0.0001).
- The procedure was well tolerated, with no instances of complete atrioventricular block or severe complications reported.
- Sustained reduction in LVOT obstruction was observed throughout the follow-up period.
Conclusions:
- TEE-guided septal ablation is an efficient and safe therapeutic option for managing LVOT obstruction in HCM.
- The procedure demonstrates sustained effectiveness in gradient reduction and is a viable alternative to other invasive treatments.
- This technique offers a promising approach for improving clinical outcomes in selected HCM patients.
Background:
Hypertrophic cardiomyopathy (HCM) can cause obstruction in the left ventricular outflow tract (LVOT), and be responsible for the onset of limiting symptoms, such as tiredness. When such symptoms are refractory to pharmacological treatment, interventionist alternative therapies can be useful, such as septal ablation through the infusion of alcohol in the coronary artery or through myectomy. Recently, the use of a radiofrequency (RF) catheter for endocardial septal ablation guided by electroanatomic mapping has proven to be efficient, despite the high incidence of complete atrioventricular block. An alternative would be the application of RF at the beginning point of the septal gradient guided by the transesophageal echocardiography (TEE). The echocardiography is an imaging method with high accuracy to determine septal anatomy.
Objective:
To assess the long term effect of septal ablation for the relief of ventricular-arterial gradient, using TEE to help place the catheter in the area of larger septal obstruction. Besides, to assess the effects of ablation on the functional class and echocardiographic parameters.
Methods:
Twelve asymptomatic patients, with LVOT obstruction, refractory to pharmacological therapy, underwent endocardial septal ablation with 8mm-tip catheters, whose placement was oriented in the region of larger obstruction, assisted by the TEE. Temperature-controlled and staggered RF applications were performed. After each application, the gradient was reassessed and a new application was performed according to the clinical criterion. The effects of RF applications were assessed both for the gradient at rest and for that provoked by the Valsalva maneuver, and considering the gradient. The differences were significant when p-value was lower than or equal to 0.05.
Results:
It was possible to observe that the mean reduction of the maximum gradients was from 96.8±34.7 mmHg to 62.7±25.4 mmHg three months after the procedure (p=0.0036). After one year, the mean of maximum gradient was 36.1±23.8 mmHg (p=0.0001). The procedure was well tolerated, without records of complete atrioventricular block nor severe complications.
Conclusion:
The TEE-guided septal ablation was efficient and safe, and the results were maintained during the clinical follow-up period. It is a reasonable option for the interventionist treatment of LVOT obstruction in HCM.
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