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Alcohol ablation via coronary angiography of the segment of hypertrophied septal myocardium at the left ventricular outflow tract for patients with HOCM.

Anesthesia is usually requested as patients will experience ischemic chest pain, (sometimes requiring postoperative opioids) and are at risk of arrhythmias for which DC reversion may be required.

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Considerations as for remote anesthesia and catheter lab.

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Considerations as for the patient with HOCM

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List of complications experienced in series of 300 patients refl.in/i7 . Events include 3rd degree AV block (30%), coronary vasospasm and perforation.

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Prehydrate with decent volume of intravenous fluid prior to induction to minimise preload reduction and exacerbation of left ventricular outflow tract obstruction (management as for HOCM)

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1L intravenous fluid or more if young patient
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TOE will be performed to visualise the hypertrophied septum and confirm the correct territory is about to be ablated by initially testing with echogenic contrast (luvovist)

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At risk of VF at injection of levovist (ultrasound contrast) into the
septal branch. Treatment will be defibrillation, CPR if required, and amiodarone if refractory VF. Consider avoiding adrenaline as this will increase contractility and worsen outflow tract obstruction. #safety

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VF may be more likely to occur if larger volumes of levovist (3-4ml cw 1ml) are used. In our case where VF occurred this was the case.
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Intubate the patient. TOE/TEE will be used to visualise area of myocardium about to be sclerosed using an echogenic contrast solution.

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Place defibrillation pads on prior to draping the patient so that is available if the patient develops a shockable arrhythmia. #safety

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Cardiologist will usually place transvenous pacing wire at beginning of the case for use in the event of complete heart block

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Video animation of the PTSME procedure produced for patients.

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