Author + information
- Lijo Varghese1
Patient initials or identifier number
Relevant clinical history and physical exam
A 35-year-old male, presented with exertional dyspnea, fatigue & palpitations for last 10 years.
• Diagnosed HOCM at age of 18 years and underwent DDDR implantation elsewhere for sequential pacing (symptomatic despite OMT).
• In view of palpitations despite DDDR & OMT, documented NSVT on Holter, referred to us for up gradation to AICD.
• Examination-Right UL BP lower than left UL by 50 mm, Left UL & bilateral leg BP same.
• EsM in aortic area.
Relevant test results prior to catheterization
• LABS-elevated ESR & CRP
• ECG-sinus, gross LVH with strain (pressure overload)
• ECHO-conc LVH with Mid-cavity obstruction with 60 mmgdt
Relevant catheterization findings
Diagnosis after Angio:
Aortoarteritis (probably Takayasu)with ascending aorta, arch & coronary involvement.
• LVH with mid-cavity obstruction.
• In view of the tight ascending aorta lesion with a significant gradient across, It was decided to treat this percutaneous.
• It was also thought that this was probably the cause of severe LVH (like supra-aortic stenosis).
Stent positioned well above coronaries & AV. Stented with Palmaz 5014 on a 16 x 40 mm balloon (deployed at 8 atm). Overdrive pacing done using a temporary pacer.
Since there was a small aneurysm between the innominate & LCCA lesions, it was decided to use covered stents simultaneously deployed in both, so as to crush an aneurysm. Used Atrium V12 8x 38 mm & 10 x 38 mm in innominate& LCCA respectively. Simultaneous kissing post-dilatation of both to 9 mm & 12 mm respectively.
• Good result after a procedure with no gradient across the ascending aorta or between both upper limbs.
• Also had LAD CTO, which was left alone since he was asymptomatic.
• Angiographic follow-up at 1 & 2 years showed the excellent result with no residual gradients & complete resolution of an aneurysm in between both covered stents.
• Rare c/o Takayasu Arteritis, with following unusual features:
• Male patient• Ascending aorta involvement (stenosis rather than dilatation and without AR) with arch involved type II
• LVH + mid-cavity obstruction, probably secondary to supra valve AS (masquerading as HOCM)
• Successful intervention (probably the first a case report of such in the literature) led to reduction in symptoms and mid-cavity gradient (60 mm to 10 mm in 2 years) and probably saved him from a need for AICD
• Diagnosis of HOCM should be confirmed by proper ECHO and if required cath. The stent positioning in a case of ascending aorta stenosis is crucial (due to proximity to coronaries & AV)