Myocardium’s power hour: alcohol septal ablation improving QOL in a post TAVR patient

Consult this Twitter case concerning a 83-year-old female, with previous medical history of HTN, CKD stage 3, 2 strokes without any disabilities and AFib without OAC

Successful alcohol septal ablation in a post-TAVR patient with persistent heart failure due to dynamic LVOTO

This case was originally published on Twitter by @gdodo92via #CardioTwitterCase

Clinical presentation

An 83-year-old female, with previous medical history of HTN, CKD Stage 3, 2 strokes without any disabilities and AFib without OAC, presents with progressive symptoms of heart failure, angina and GI bleeding. Physical examination revealed a rude systolic 3+/6+ aortic murmur and signs of pulmonary congestion besides a low BMI and important frailty.

Echo was performed showing severe aortic stenosis (Mean VA 0,6 cm²) with preserved LVEF, concentric LV hypertrophy with a 16 mm basal septum, peak gradient was dynamic and around 100 mmHg and moderate mitral regurgitation.

Case Management

Accounting for heart failure symptoms, Heyde's Syndrome (other bleeding causes were ruled out), severe aortic stenosis and a high bleeding risk, TAVR was the treatment option.

The procedure was performed through right femoral access and an M sized Accurate Valve (Boston Scientific) was deployed. A +1/+2 paravalvular leak maintained even after 1:1 post-dilatation. Decision was made to stop the procedure to mitigate the risk for annular rupture. The LVOT gradient maintained elevated but no hemodynamic deterioration occurred at the time.

The patient was discharged, however, had 2 early readmissions for decompensated HF with severe congestion, class 4 dyspnea and failure to optimize optimal medical treatment. Also, a permanent Pacemaker was implanted for advanced AV block and even with 100% AV pacing at a 55 bpm, the LVOT gradient remained high.

Decision was then made to perform an Alcohol Septal Ablation (ASA) to relieve IV gradient and try to improve the patient's symptoms and QOL, which was done by accessing the first septal branch (with a good diameter) and, after contrast injection with an inflated Emerge OTW 2,5 x 8 mm Balloon (Boston Scientific), the myocardial area of interest was revealed and 1 ml of Absolute Alcohol was slowly infused without any complications. The LVOT gradient dropped almost 100 mmHg, the MR grade improved and no additional branches needed to be ablated. The patient evolved with marked symptom improvement without any local complications and was discharged a few days later.

Summary

In patients with severe AS and LV hypertrophy with dynamic obstruction who are submitted to the AVR (either TAVR or SAVR), there is a risk of hypotension and shock due to acute resistance relief that causes a Venturi effect through the LVOT with SAM and gradient augmentation. In these cases, ASA is paramount in restoring the patient's stability. However, if it does not happen, the question remains whether the septum ablation should be assessed in a routine fashion or only if failure to thrive develops post procedurally despite OMT.