Alcohol septal ablation (ASA) was first performed in 1994 as an alternative to septal myectomy in patients with hypertrophic obstructive cardiomyopathy and symptoms refractory to optimal medical therapy. Patient selection is based on careful individual evaluation of symptoms, associated comorbidities, and echocardiographic and angiographic parameters. Studies have shown that the clinical success of ASA in patients with provocable obstruction is comparable to that in patients with obstruction at rest. The use of myocardial contrast echocardiography as an adjunct to the procedure has yielded higher success rates despite lower infarct sizes, in turn reducing complication rates. The principal complication of the procedure is atrioventricular block, for which permanent pacing is required in approximately 10% of patients. Evidence from non-randomized trials and meta-analyses indicates that ASA is similar to myectomy with respect to hemodynamic and functional improvement and mortality. Surgery is often preferred in younger patients and in those with severe hypertrophy of the septum (e.g., ≥30 mm). ASA is usually selected for elderly patients and those with comorbid conditions that increase the risk of surgery.
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