Venous Septal Alcohol Ablation as a Salvage Strategy in Obstructive Hypertrophic Cardiomyopathy

Septal alcohol ablation (SAA) is an established septal reduction therapy for symptomatic obstructive hypertrophic cardiomyopathy (HCM); however, its efficacy depends on favorable septal arterial anatomy. In a subset of patients, arterial access may be limited by unfavorable anatomy or prior septal artery occlusion, rendering conventional SAA ineffective. We report the first case series describing venous SAA as an alternative and salvage strategy. Two symptomatic men with obstructive HCM underwent venous septal ethanol delivery after inadequate arterial septal ablation. In the first case, limited gradient reduction after arterial SAA prompted adjunctive venous ethanol infusion via the coronary sinus, resulting in sustained hemodynamic improvement. In the second case, prior arterial SAA had led to septal artery occlusion; repeat arterial intervention failed, and venous septal ethanol infusion using a controlled balloon-isolated technique achieved immediate and durable gradient reduction. At the 6-month follow-up, both patients demonstrated marked symptomatic improvement and persistent left ventricular outflow tract gradient reduction without conduction disturbances. Venous SAA may represent a feasible salvage strategy in carefully selected patients with obstructive HCM.