Skip to main content
Download PDF

Intra-cardiac echocardiography in alcohol septal ablation: a prospective comparative study against trans-thoracic echocardiography

Echo Research & Practice volume 2, pages 9–17 (2015)Cite this article

Abstract

Alcohol septal ablation (ASA) in hypertrophic obstructive cardiomyopathy reduces left ventricular outflow tract gradients. A third of patients do not respond; inaccurate localisation of the iatrogenic infarct can be responsible. Transthoracic echocardiography (TTE) using myocardial contrast can be difficult in the laboratory environment. Intra-cardiac echocardiography (ICE) provides high-quality images. We aimed to assess ICE against TTE in ASA. The ability of ICE and TTE to assess three key domains (mitral valve (MV) anatomy and systolic anterior motion, visualisation of target septum, adjacent structures) was evaluated in 20 consecutive patients undergoing ASA. Two independent experts scored paired TTE and ICE images off line for each domain in both groups. The ability to see myocardial contrast following septal arterial injection was also assessed by the cardiologist performing ASA. In patients undergoing ASA, ICE was superior in viewing MV anatomy (P=0.02). TTE was superior in assessing adjacent structures (P=0.002). There was no difference in assessing target septum. Myocardial contrast: ICE did not clearly identify the area of contrast in 17/19 patients due to dense acoustic shadowing (8/19) and inadequate opacification of the myocardium (6/19). ICE only clearly localised contrast in 2/19 cases. ICE does not visualise myocardial contrast well and therefore cannot be used to guide ASA. TTE was substantially better at viewing myocardial contrast. There was no significant difference between ICE and TTE in the overall ability to comment on cardiac anatomy relevant to ASA.

References

  1. Elliott P, McKenna WJ 2004 Hypertrophic cardiomyopathy. Lancet 363 1881–1891. (doi:10.1016/S0140-6736(04)16358-7)

    Article  CAS  Google Scholar 

  2. Maron MS, Olivotto I, Betocchi S, Casey SA, Lesser JR, Losi MA, Cecchi F, Maron BJ 2003 Effect of left ventricular outflow tract obstruction on clinical outcome in hypertrophic cardiomyopathy. New England Journal of Medicine 348 295–303. (doi:10.1056/NEJMoa021332)

    Article  Google Scholar 

  3. Maron MS, Olivotto I, Zenovich AG, Link MS, Pandian NG, Kuvin JT, Nistri S, Cecchi F, Udelson JE, Maron BJ 2006 Hypertrophic cardiomyopathy is predominantly a disease of left ventricular outflow tract obstruction. Circulation 114 2232–2239. (doi:10.1161/CIRCULATIONAHA.106.644682)

    Article  Google Scholar 

  4. Sorajja P, Ommen SR, Holmes DR Jr Dearani JA, Rihal CS, Gersh BJ, Lennon RJ, Nishimura RA 2012 Survival after alcohol septal ablation for obstructive hypertrophic cardiomyopathy. Circulation 126 2374–2380. (doi:10.1161/CIRCULATIONAHA.111.076257)

    Article  Google Scholar 

  5. Jensen MK, Prinz C, Horstkotte D, van Buuren F, Bitter T, Faber L, Bundgaard H 2013 Alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy: low incidence of sudden cardiac death and reduced risk profile. Heart 99 1012–1017. (doi:10.1136/heartjnl-2012-303339)

    Article  Google Scholar 

  6. Nagueh SF, Groves BM, Schwartz L, Smith KM, Wang A, Bach RG, Nielsen C, Leya F, Buergler JM, Rowe SK et al. 2011 Alcohol septal ablation for the treatment of hypertrophic obstructive cardiomyopathy a multicenter North American registry. Journal of the American College of Cardiology 58 2322–2328. (doi:10.1016/j.jacc.2011.06.073)

    Article  Google Scholar 

  7. Jensen MK, Almaas VM, Jacobsson L, Hansen PR, Havndrup O, Aakhus S, Svane B, Hansen TF, Køber L, Endresen K et al. 2011 Long-term outcome of percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: a Scandinavian multicenter study. Circulation. Cardiovascular Interventions 4 256–265. (doi:10.1161/CIRCINTERVENTIONS.110.959718)

    Article  Google Scholar 

  8. Sherrid MV, Chaudhry FA, Swistel DG 2003 Obstructive hypertrophic cardiomyopathy: echocardiography, pathophysiology, and the continuing evolution of surgery for obstruction. Annals of Thoracic Surgery 75 620–632. (doi:10.1016/S0003-4975(02)04546-0)

    Article  Google Scholar 

  9. van Dockum WG, ten Cate FJ, ten Berg JM, Beek AM, Twisk JW, Vos J, Hofman MB, Visser CA, van Rossum AC 2004 Myocardial infarction after percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: evaluation by contrast-enhanced magnetic resonance imaging. Journal of the American College of Cardiology 43 27–34. (doi:10.1016/j.jacc.2003.08.031)

    Article  Google Scholar 

  10. Amano Y, Kitamura M, Yamada F, Aita K, Takayama M, Tachi M, Kumita S Magnetic resonance imaging of microvascular obstruction in hypertrophic obstructive cardiomyopathy after percutaneous transluminal septal myocardial ablation Acta Radiologica 2014 [in press] (doi:10.1177/0284185114559871)

    Google Scholar 

  11. Wallace EL, Thompson JJ, Faulkner MW, Gurley JC, Smith MD 2013 Septal perforator anatomy and variability of perfusion bed by myocardial contrast echocardiography: a study of hypertrophic cardiomyopathy patients undergoing alcohol septal ablation. Journal of Interventional Cardiology 26 604–612. (doi:10.1111/joic.12068)

    Article  Google Scholar 

  12. Rusu MC, Petrescu CI, Niculescu V, Ionescu N, Vlad M 2006 Considerations on the left papillary muscles microangioarchitecture. Romanian Journal of Morphology and Embryology 47 63–66.

    CAS  PubMed  Google Scholar 

  13. Cooper RM, Shahzad A, Stables RH 2013 Current status of nonsurgical septal reduction therapy in hypertrophic obstructive cardiomyopathy. Interventional Cardiology 5 427–439. (doi:10.2217/ica.13.33)

    Article  Google Scholar 

  14. Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H et al. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 124 2761–2796. (doi:10.1161/CIR.0b013e318223e230)

    Article  Google Scholar 

  15. Steggerda RC, Balt JC, Damman K, van den Berg MP, Ten Berg JM 2013 Predictors of outcome after alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy. Special interest for the septal coronary anatomy. Netherlands Heart Journal 21 504–509. (doi:10.1007/s12471-013-0453-4)

    Article  CAS  Google Scholar 

  16. Cooper RM, Shahzad A, Stables RH Alcohol septal ablation for hypertrophic obstructive cardiomyopathy: safe and apparently efficacious but does reporting of aggregate outcomes hide less-favourable results, experienced by a substantial proportion of patients? Journal of Invasive Cardiology 2014 [in press]

    Google Scholar 

  17. Ponnuthurai FA, van Gaal WJ, Burchell A, Mitchell AR, Wilson N, Ormerod OJ 2009 Safety and feasibility of day case patent foramen ovale (PFO) closure facilitated by intracardiac echocardiography. International Journal of Cardiology 131 438–440. (doi:10.1016/j.ijcard.2007.07.141)

    Article  Google Scholar 

  18. MacDonald ST, Newton JD, Ormerod OJ 2011 Intracardiac echocardiography off piste? Closure of the left atrial appendage using ICE and local anesthesia.. Catheterization and Cardiovascular Interventions 77 124–127. (doi:10.1002/ccd.22652)

    Article  Google Scholar 

  19. Ludman P. British Cardiovascular Intervention Society Audit returns 2011, 2012.

    Google Scholar 

  20. Wharton G, Allen J, Brewerton H, Jones R, Kanagala P, Lloyd G, Masani N, Mathew T, Oxborough D, Rana B, et al. British Society of Echocardiography Minimum Dataset; A Standard Transthoracic Echo 2012; http://www.bsecho.org/tte-minimum-dataset/, 2012.

    Google Scholar 

  21. Reis RL, Bolton MR, King JF, Pugh DM, Dunn MI, Mason DT 1974 Anterion-superior displacement of papillary muscles producing obstruction and mitral regurgitation in idiopathic hypertrophic subaortic stenosis. Operative relief by posterior–superior realignment of papillary muscles following ventricular septal myectomy. Circulation 50 (2 Suppl) Ii181–Ii188.

    CAS  PubMed  Google Scholar 

  22. Kaul S 2008 Myocardial contrast echocardiography: a 25-year retrospective. Circulation 118 291–308. (doi:10.1161/CIRCULATIONAHA.107.747303)

    Article  Google Scholar 

  23. Jiang L, Levine RA, King ME, Weyman AE 1987 An integrated mechanism for systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy based on echocardiographic observations. American Heart Journal 113 633–644. (doi:10.1016/0002-8703(87)90701-0)

    Article  CAS  Google Scholar 

  24. Grigg LE, Wigle ED, Williams WG, Daniel LB, Rakowski H 1992 Transesophageal Doppler echocardiography in obstructive hypertrophic cardiomyopathy: clarification of pathophysiology and importance in intraoperative decision making. Journal of the American College of Cardiology 20 42–52. (doi:10.1016/0735-1097(92)90135-A)

    Article  CAS  Google Scholar 

  25. Maron MS, Olivotto I, Harrigan C, Appelbaum E, Gibson CM, Lesser JR, Haas TS, Udelson JE, Manning WJ, Maron BJ 2011 Mitral valve abnormalities identified by cardiovascular magnetic resonance represent a primary phenotypic expression of hypertrophic cardiomyopathy. Circulation 124 40–47. (doi:10.1161/CIRCULATIONAHA.110.985812)

    Article  CAS  Google Scholar 

  26. Gietzen FH, Leuner CJ, Raute-Kreinsen U, Dellmann A, Hegselmann J, Strunk-Mueller C, Kuhn HJ 1999 Acute and long-term results after transcoronary ablation of septal hypertrophy (TASH). Catheter interventional treatment for hypertrophic obstructive cardiomyopathy. European Heart Journal 20 1342–1354. (doi:10.1053/euhj.1999.1520)

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool, L14 3PE, UK

    Rodney H. Stables MA DM BM BCH FRCP

  2. Oxford John Radcliffe Hospital, Oxford, UK

    Robert M. Cooper MBChB MRCP, Adeel Shahzad MBBS MRCP & Oliver Ormerod DM FRCP

  3. Rigshospitalet, Copenhagen, Denmark

    James Newton MBChB MRCP MD, Niels Vejlstrup MD PhD & Anna Axelsson MD

  4. Royal Liverpool University Hospital, Liverpool, UK

    Vishal Sharma MD FRCP FESC

Authors
  1. Robert M. Cooper MBChB MRCP
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Adeel Shahzad MBBS MRCP
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. James Newton MBChB MRCP MD
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Niels Vejlstrup MD PhD
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Anna Axelsson MD
    View author publications

    You can also search for this author inPubMed Google Scholar

  6. Vishal Sharma MD FRCP FESC
    View author publications

    You can also search for this author inPubMed Google Scholar

  7. Oliver Ormerod DM FRCP
    View author publications

    You can also search for this author inPubMed Google Scholar

  8. Rodney H. Stables MA DM BM BCH FRCP
    View author publications

    You can also search for this author inPubMed Google Scholar

Corresponding author

Correspondence to Robert M. Cooper MBChB MRCP.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the articles Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the articles Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Cooper, R.M., Shahzad, A., Newton, J. et al. Intra-cardiac echocardiography in alcohol septal ablation: a prospective comparative study against trans-thoracic echocardiography. Echo Res Pract 2, 9–17 (2015). https://doiorg.publicaciones.saludcastillayleon.es/10.1530/ERP-15-0002

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1530/ERP-15-0002

Key Words

Echo Research & Practice

ISSN: 2055-0464

Contact us