ALCOHOL ABLATION OF THE HEART – CASE REPORT

Abstract 
Alcohol septal ablation (ASA) is a minimally invasive, non-surgical treatment for hypertrophic cardiomyopathy. This condition causes the heart tissue to thicken, restricting blood flow. Reduced blood flow causes symptoms such as shortness of breath and fatigue. Alcohol septal ablation restores normal blood flow by damaging and shrinking the thickened tissue. The procedure does not damage normal tissue. Providers perform this procedure on people who have HCM and, despite medication, have symptoms of shortness of breath and/or fatigue with exertion.1 
Alcohol ablation has been successfully used in the ablation of ventricular tachycardiaventricular fibrillation, and atrial fibrillation. 2 
Material and Methods 
The procedure is performed under the control of the Toshiba Infinix discoscope, in the coronary angiography program. Diascopy parameters are 86 kVp, 800 mA, fluoroscopy: 5 fr/sec, radiography 10 fr/sec, pulse width 12 bit, matrix size 1024x1024. The procedure was performed in the RAO 30° CRANIAL 30° projection, and with a magnification of 20 cm. Visipaque 320 contrast agent was used, which was injected via the MEDRAD Avanta automatic injector. Contrast injection parameters were flow rate 2 ml/s and volume 4 ml. A total of 120 ml of contrast agent was given. To confirm the results of AA, ultrasound contrast agent SONOVIEW was used. Monitoring of contrast flow through the myocardium was done with a SIEMENS ultrasound device. 
Case study 
The patient, 65 years old, is hospitalized at the Department of Interventional Cardiology for an invasive cardiac procedure under the diagnosis of hypertrophic obstructive cardiomyopathy. Echocardiography after the procedure: The left atrium is dilated and elongated. Mitral valve morphologically sclerotically changed, functionally mild to moderate MR 2+ (VC 4 min) Left ventricle of regular dimensions, concentrically hypertrophic walls. Type 3 SAM is being verified. Preserved left ventricular systolic function (EF 60%). 
Conclusion 
We present the case of an elderly patient with symptomatic obstructive hypertrophic cardiomyopathy. Despite the modification of drug therapy, significant obstructive pressure in the outflow tract of the left ventricle still persisted. After adequate preparation, septal alcohol ablation is performed with echo control of the procedure. Postprocedurally, the dynamics of cardioselective enzymes are monitored with ultrasound verified hypokinesis of the S2 irrigation area. Due to intermittent complete AV block, a permanent electrostimulator is implanted. At the 
 


INTRODUCTION
Alcohol septal ablation (ASA) is a minimally invasive, non-surgical treatment for hypertrophic cardiomyopathy.This condition causes the heart tissue to thicken, restricting blood flow.Reduced blood flow causes symptoms such as shortness of breath and fatigue.Alcohol septal ablation restores normal blood flow by damaging and shrinking the thickened tissue.The procedure does not damage normal tissue.Providers perform this procedure on people who have HCM and, despite medication, have symptoms of shortness of breath and/or fatigue with exertion. 1cohol ablation has been successfully used in the ablation of ventricular tachycardia, ventricular fibrillation, and atrial fibrillation. 2rint: ISSN 2232-8726 Online: ISSN 2637-3297

CASE STUDY
The patient, 65 years old, is hospitalized at the Department of Interventional Cardiology for an invasive cardiac procedure under the diagnosis of hypertrophic obstructive cardiomyopathy.The patient is in a normal state of consciousness and orientation, communicative and eupnoic at rest.Denies allergies.He does not consume alcohol or tobacco.On admission TA 108/70 mmHg, pulse 76/min, Lungs: auscultation shows normal breathing sounds with signs of obstructive and stagnant phenomena.Heart: arrhythmic action, clear tones, no presence of noise.Abdomen is soft and painless.Extremities symmetrical with oedema of both legs.ECG on admission fr 83/ min means CLK.
An invasive coronary angiography is performed through the right transradial approach, which verifies the orderly coronary system (Figure 1 and 2).Using the left transradial approach, a pigtail catheter is placed in the LV and connected to a hemodynamic monitoring system.A temporary ES heart electrode was placed through the right transfemoral approach.Using the right transradial approach, the LCA is probed with an EBU guiding catheter 3.5 (Figure 3).The hemodynamic monitoring system measures pressure gradients that go up to 100 mmHg post-extrasystolic (Figure 4).Then the BMW interventional wire is inserted into the strong S2 and an OTW balloon 2.0x15mm is placed.The wire is pulled out and Fig. 5. Fig. 6.This is followed by the injection of a mixture of contrast and agitated saline solution through the balloon, which confirms complete occlusion of S2 without complete return of contrast, and echocardiographically verifies the opacification of the basal IV septum (Figure 7 and 8).This is followed by the administration of 3 ml of 96% alcohol in separate injections of 1 ml each, followed by rinsing with saline solution.pearance of S2 after ablation (Figure 9).Other parts of the left coronary basin are intact as before the procedure.
Clinically expected appearance of precordial pain and reperfusion arrhythmias with a satisfactory drop in gradient and angiographic ap-  Marshall-treated patients.Adverse events were similar between groups.Among patients with persistent AF, addition of vein of Marshall ethanol infusion to catheter ablation, compared with catheter ablation alone, increased the likelihood of remaining free of AF or atrial tachycardia at 6 and 12 months.Further research is needed to assess longer-term efficacy. 4ere is little information regarding long-term mortality comparing the 2 most common procedures for septal reduction for obstructive hypertrophic cardiomyopathy (HCM), alcohol septal ablation (ASA), and septal myectomy.We evaluated outcomes of 3,859 patients who underwent ASA or septal myectomy in 3 specialized HCM centres.All-cause mortality was the primary endpoint of the study.This study sought to compare the long-term mortality of patients with obstructive HCM following septal myec-

DISCUSSION
The hypothesis that production of ischemia or cooling of an arrhythmogenic area or pathway could interrupt tachycardias was tested by subselective catheterization of the coronary artery supplying the site of origin of ventricular tachycardia (9 patients), the accessory pathway (2 patients) and the site of origin of atrial tachycardia (1 patient).Ventricular tachycardia was reproducibly terminated and reinduction was temporarily prevented in 8 of the 9 patients by occlusion of the artery or administration of iced isotonic saline.Block in the accessory pathway was obtained in 1 of the 2 patients with Wolff-Parkinson-White syndrome.Selective cooling through the atrioventricular nodal artery in 1 patient terminated his circus movement tachycardia.Reproducible termination of a continuous atrial tachycardia was obtained by cooling of the atrial branch supplying the site of origin of the arrhythmia.These data demonstrate the feasibility of identification and selective catheterization of the coronary artery branch supplying blood to an arrhythmogenic area or pathway and suggest a new possibility for treatment of tachycardias by permanently blocking the blood supply to the site of origin or pathway of a tachycardia.This impact on survival is independent of other known factors but may be influenced by unmeasured confounding patient characteristics. 5best evidence topic in cardiac surgery was written according to a structured protocol.The question addressed was whether surgical septal myectomy (SM) is more beneficial than alcohol septal ablation (ASA) in patients with hypertrophic obstructive cardiomyopathy.Altogether 218 articles were found using the reported search, of which 15 studies represented the best evidence to answer the clinical question.There were 14 observational studies and 1 meta-analysis study.66 left ventricle with preserved systolic function of the same.The patient reports a post-procedural significant improvement in tolerance to physical exertion.ASA is preferred due to the often significant comorbidities in elderly patients, due to the fact that it is not necessary to put the patient under general anesthesia and that the post-procedural recovery is incomparably faster compared to surgical intervention.Because of the above, ASA should not be considered as an alternative to surgical intervention.Depending on the center, the training of the team as well as the experience of the same, it is necessary to carry out the selection of patients.

CONCLUSION
We present the case of an elderly patient with symptomatic obstructive hypertrophic cardiomyopathy.Despite the modification of drug therapy, significant obstructive pressure in the outflow tract of the left ventricle still persisted.After adequate preparation, septal alcohol ablation is performed with echo control of the procedure.Postprocedurally, the dynamics of cardioselective enzymes are monitored with ultrasound verified hypokinesis of the S2 irrigation area.Due to intermittent complete AV block, a permanent electrostimulator is implanted.At the control examination, echo verified normal pressure in the outlet tract of the