Percutaneous Alcohol SeptalAblation for HypertrophicCardiomyopathy and Left AtrialAppendage Closure forPrevention of Stroke Flashcards
What is the indication for PTSMA in patients with HCM?
Drug refractory severe symptoms, defined as NYHA Class III or IV
NYHA stands for New York Heart Association, a classification system for heart failure severity.
What is the next step in managing a patient with heart rate of 85 and normal intervals?
Uptitration of beta-blockers
What percentage of HCM patients experience LVOT obstruction?
Up to 70%
What are provocative maneuvers used for in assessing LVOT obstruction?
Decrease preload, decrease afterload, or increase cardiac contractility
What is the most typical form of provocation to assess LVOT obstruction?
Resting echocardiography with Valsalva maneuver
What is the documented LVOT gradient threshold for considering alcohol septal ablation?
50 mm Hg or more
What factors must be considered for effective PTSMA?
- Mechanism of LVOT obstruction must be SAM of the anterior mitral valve leaflet
- No intrinsic structural abnormalities of the mitral valve
- No severe CAD amenable to CABG
- No atypical patterns or excessive degrees of septal hypertrophy
What is the mortality rate for both myectomy and alcohol septal ablation at experienced centers?
<1%
What is the training requirement for operators performing alcohol septal ablation?
Perform the first 5 procedures under the proctorship of an experienced operator
What is the typical reduction in LVOT gradients after alcohol septal ablation?
More than 50%, with the majority reduced by 90% or more
What is the most common conduction abnormality following alcohol septal ablation?
RBBB (Right Bundle Branch Block)
What is the purpose of placing a temporary pacemaker wire in the right ventricle prior to alcohol septal ablation?
To manage transient complete heart block, which can occur in up to 50% of patients
What does MCE stand for in the context of alcohol septal ablation?
Myocardial Contrast Echocardiography
What occurs if retrograde spillover of alcohol happens during infusion?
MI secondary to abrupt closure of the LAD distal to the targeted branch
What is the recommended volume of ethanol for alcohol ablation?
1 to 2 mL
What is the typical volume of alcohol infusion for septal ablation?
1 to 2 mL
It is adequate as long as the appropriate target septal perforator branch is chosen.
What are the current recommendations for alcohol infusion volume in relation to septum thickness?
Roughly the same volume in milliliters as the thickness of the septum or the diameter of the septal perforator
Modern practice may infuse as little as 0.5 mL of alcohol if the target area opacifies fully.
What is the incidence of pacemaker placement after alcohol septal ablation?
6% to 7%
This reflects improved safety in the modern era.
Why must the temporary pacemaker wire remain in place after the procedure?
Due to the high incidence of complete heart block that can occur during or following the procedure
How long should monitoring occur in an intensive care unit after alcohol septal ablation?
48 hours
Telemetry should continue for the duration of the patient’s stay, usually 4 to 5 days.
What hemodynamic change distinguishes dynamic LVOT obstruction from aortic stenosis?
Decrease in aortic pulse pressure and increase in LVOT gradient following a PVC
What is a potential complication of alcohol septal ablation?
Development of lethal ventricular arrhythmias due to scar tissue
What is the risk of sudden death and ventricular tachyarrhythmia after alcohol septal ablation?
No increase in attributable risk of sudden death
What is the primary aim of surgical myectomy?
To excise approximately 5 g of muscle from the basal anterior portion of the interventricular septum
What is the mortality rate associated with surgical myectomy?
0% to 3%
What is the recommended treatment for healthy young patients with HCM?
Myectomy
What is the gold standard mechanical intervention for HCM according to 2011 guidelines?
Surgical myectomy with a Class IIa indication
What defines a successful outcome for alcohol septal ablation?
At least a 50% reduction in resting and/or provokable gradient
What common symptom do patients experience during alcohol infusion?
Chest pain
How should alcohol be administered during septal ablation?
Infused into the central lumen of the balloon at a rate of 1 mL per 60 to 120 seconds
What is a significant risk associated with rapid bolus injection of alcohol?
Higher incidences of complete heart block
What is the typical response to chest pain during alcohol infusion?
IV analgesic agents (i.e., morphine and fentanyl)
What is the significance of the Brockenbrough–Braunwald–Morrow sign?
Indicates decreased stroke volume due to dynamic obstruction
What should be monitored for patients after alcohol septal ablation?
Telemetry and daily ECG to track progression of conduction disease
What is the recommended follow-up for cardiac biomarkers after alcohol septal ablation?
Cycle and follow a pattern similar to that seen following an acute MI
What is the typical volume of alcohol infusion preferred to remain under during ablation?
<3 mL
What is the immediate benefit of alcohol septal ablation?
Reduction in resting and/or provoked gradients, leading to improved stroke volume and cardiac output.
Alcohol septal ablation also decreases SAM-related mitral regurgitation and improves clinical outcomes.
What are the long-term benefits of relief of obstruction in alcohol septal ablation?
Improved functional status and likely continued clinical benefits that evolve out to 1 to 3 years from the procedure.
It can also improve diastolic function and produce global regression of left ventricular hypertrophy.
What should be evaluated first if a patient has mild aortic regurgitation before septal reduction therapy?
Transesophageal echocardiogram (TEE) to evaluate for subaortic membrane.
Aortic regurgitation is common with subaortic membranes.
In which patient demographics is alcohol septal ablation contraindicated according to national guidelines?
Children <21 and discouraged in adults <40.
Efficacy appears reduced in midventricular obstruction and/or septal thickness >30 mm.
What was the main finding of the LAOS trial regarding surgical closure of the LAA?
44% of patients had inadequate closure eight weeks postoperatively, defined as residual blood flow into the appendage.
The trial demonstrated that surgical techniques can lead to complications such as atrial tears.
What was the purpose of the PROTECT AF trial?
To examine the use of the Watchman LAA occluder vs. conventional warfarin therapy in patients with a CHADS2 score of 1 or more.
Patients were monitored for device closure effectiveness post-implantation.
What was the incidence of serious pericardial effusion in the PROTECT AF trial?
4.8% in the intervention arm.
This adverse event is related in part to operator experience.
What does the CMS require from institutions performing LAO procedures?
Participation in the National Cardiovascular Data Registry (NCDR).
This registry analyzes procedural safety and device effectiveness.
What is the recommendation regarding anticoagulation when a residual leak >5 mm is present after Watchman device implantation?
Continue warfarin therapy until the leak is ≤5 mm on subsequent imaging.
Ongoing investigation is required as low event rates make therapeutic decisions difficult.
What are the criteria for patients to be appropriate candidates for the Watchman device?
CHADS2 score of at least 2 or CHA2DS2-VASc score of at least 3.
Patients with another indication for ongoing systemic anticoagulation are not suitable candidates.
True or False: The Watchman device was found to be superior to warfarin therapy in the PROTECT AF trial.
False.
The Watchman device was noninferior but not superior to warfarin therapy.
What is the risk associated with the LARIAT system?
Higher risk of pericardial effusion related to epicardial access and trauma to the LAA and surrounding tissue.
Late pericardial effusions have been reported due to inflammation related to LA necrosis.
Fill in the blank: The _______ system utilizes both transseptal and epicardial access to deliver and tighten a snare around the LAA ostium.
LARIAT
What should be done if a 24-mm Watchman device is deployed and there is a residual jet of 6 mm?
The device should be removed and a larger device implanted.
A properly sized device will expand to a diameter between 80% and 92% of its original diameter.
What is the relationship between the rates of ischemic stroke in the Watchman and warfarin groups in the PROTECT AF trial?
The rates of ischemic stroke were equivalent between the two groups.
5.2% for the device arm and 4.1% for the warfarin arm.
