CardioExchange Archive

CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

April 1st, 2010

Alcohol or the Knife?

Your patient with symptomatic obstructive hypertrophic cardiomyopathy is faced with a choice and asks, “If it were you, would you have alcohol ablation or myectomy?”

Recent U.S. studies show that alcohol ablation is safe and effective (i.e., low complication rate, durable hemodynamic effects, and good long-term survival), whereas European studies suggest it is not (due to long-term adverse effects, such as life-threatening arrhythmias).  How would you respond to your patient?

Categories: Cardiac Surgery, General
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4 Responses to “Alcohol or the Knife?”

  1. David May, MD, PhD says:
    April 10, 2010 at 7:23 am

    In the past year I have sent four patients to “the knife” and none to “alcohol” ( although I am sure several of them had to go home and have a drink after the discussion). All have done exceeding well. At the time of their referral, the most recent data from US centers was not available, however it would not at this point change my referral. Surgical repair does allow discussion of the long term results with the patient. The current alcohol septal ablation data generally allows only a 4.5 – 5.5 year follow up (ranging from a few months to about 10 years), well within the lifespan of a 45 year old with HOCM.

  2. Matthew R Wolff, MD says:
    April 15, 2010 at 11:02 am

    I offer ETOH septal ablation only to patients who have truly failed medical therapy and are truly disabled by traditional symptoms, typically with a history of having tried multiple drug combinations over at least several years Correctly or not, I almost always have an ICD implanted and give DDD pacing at least a brief trial. In this small and highly selective cohort, my anecdotal experience with ETOH SA has been excellent, with uniformly significant improvements in functional status and reductions in MR as well as outflow tract gradients. So, I personally would chose ETOH (septally as well as orally) if I met these qualifying criteria.

  3. Ellen Keeley, MD, MS says:
    April 15, 2010 at 1:10 pm

    “the knife”

    I would recommend surgical myectomy due to the fact that there is limited long-term outcome data following septal ablation, particularly regarding risk of ventricular arrhythmias. I might be convinced otherwise with additional favorable follow-up data on long-term ventricular function and risk of sudden death in patients treated with septal ablation. Until then, I would recommend “the knife”.

  4. Steven Bailey, MD says:
    April 15, 2010 at 10:13 pm

    Alcohol, Knife or Coil

    I have a different view of this question. The patients who have myectomy tend to be different than those who undergo septal ablation. Myectomy tends to be done in younger patients, those with more structural mitral valve disease and is based some what on referral patterns and acceptable coronary anatomy (septal perforators)

    The recent meta analysis by Agarwal et al in J Am Coll Cardiol, 2010; 55:823-834, suggests that there is no difference in survival or functional status but there is more heart block. In patients with suitable anatomy and increased co morbidities I use this as one of my therapeutic options. Recent data from Smalling et al suggest that coils rather than alcohol may offer even better outcomes.