What is Septal Ablation (TASH/PTSMA) ?

This is a nonsurgical interventional treatment. The septal myocardium supplied by 1^st septal branch of left anterior descending artery is destroyed by alcohol, by percutaneous technique.

It creates limited myocardial infarction and reduces LV outflow obstruction. It reduces mitral incompetence and improves relaxation. Improvement occurs in almost 90 per cent.

However there is some concern about 2 complications viz. Heart block which needs pacing in a few patients. There is a theoretical concern that myocardial scar that follows infarction might lead to ventricular arrhythmias. It is therefore a preferred option in patients who already have a pacemaker.

ICD in place or where surgery is contraindicated because of other medical conditions. It is however being widely used in select centres.

ICD Implantation

It is used as a method of secondary prevention for cardiac arrest or history of sustained hemodynamically unstable ventricular tachycardia. For primary prevention, it is used with history of sudden death in family with history of sustained ventricular tachycardia.

Surgical

Septal Myotomy/Myectomy (Fig 5.8) it is widely used. About 5 gms. of hypertrophied septum are removed using a tranaortic approach (Morrow procedure). It gives sysmptomatic relief in almost 70-90 per cent of patients. It should be preferred in younger patients and in
whom septal ablation has failed. Occasionally mitral valve replacement or suture plication of
anterior mitral leaflet are also employed.