November 27, 1998

Artificial "heart attack" can correct rare cardiac defect

Doctors at the MGH are the first in the region to offer a new procedure for treating an unusual, debilitating heart defect. The treatment, called septal ablation or reduction, shrinks an overgrowth of heart muscle tissue by means of a controlled, artificially induced heart attack. It is appropriate for patients in whom the tissue overgrowth blocks the flow of blood out of the heart and for whom standard treatment with medications has not been effective.

More than half a million people in this country have a genetic defect called hypertrophic cardiomyopathy, in which a portion of the heart muscle is thickened and functions abnormally. A sizeable percentage of this group has obstructive cardiomyopathy; in their case, the thickened area is predominantly in the wall separating the two sides of the heart. The position of the enlargement is such that the passage of blood from the left ventricle, the heart's major pumping chamber, out to the body through the aorta is blocked. As a result, patients experience shortness of breath, chest pain, dizziness or fainting. In very rare instances, the first symptom of any type of hypertrophic cardiomyopathy is sudden death of a previously healthy individual.

Michael Fifer, MD, the cardiologist leading the MGH team offering the new procedure, notes that most patients with this condition can be treated successfully with medications. When that does not work, traditional treatment is to remove the enlarged muscle surgically, an operation that carries a moderate level of risk. In the new approach, a small catheter is threaded into the coronary artery branch feeding the enlarged area. After the catheter's position is carefully confirmed with echocardiography, pure ethyl alcohol is injected into the obstruction, killing off the excess tissue.

"Because this produces a real heart attack, we must monitor the patients very carefully throughout the procedure," Fifer says. "The most common side effect is a slowing of the heart's rhythm, which may require the implantation of a pacemaker, something some of these patients already have. We also are very careful in selecting exactly where to inject the alcohol, which helps avoid causing the rhythm disturbance."

While patients having the overgrown tissue removed surgically must stay in the hospital for a week after the operation and spend several weeks recuperating, those having the new technique usually can go home the second or third day after the procedure.

Gloria Avanzato was the first to undergo the procedure at the MGH in September. "Before I had the procedure I was falling a lot, getting dizzy, losing my breath just from walking across a room," she says. "Now I have a lot more energy; I'm surprised at how much I'm able to do. When Dr. Fifer explained this procedure and gave me the choice of it or an operation, I decided to go along with the procedure. I'm glad I did."

Fifer notes that several MGH physicians are key to offering the new, minimally invasive therapy. "Dr. Michael Picard does the echocardiography that helps us pinpoint the exact spot we should target. Dr. Igor Palacios is the expert in placing the catheter for alcohol injection. And Dr. Gus Vlahakes in Cardiac Surgery, who has been a real advocate for this procedure, provides surgical consultation and backup," he says.

"For those patients this procedure can help," Fifer adds, "it offers significant relief of symptoms without going through a risky and inconvenient operation."

In obstructive hypertrophic cardiomyopathy, enlargement of the septum – the wall separating the two halves of the heart – blocks normal flow of blood.