Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 74 year-old woman with obstructive hypertrophic cardiomyopathy admitted to our hospital with the complaints of fatigue and dyspnea on effort,despite of medication (β-blocker). Her functional capacity was in New York Heart Association class III.
Relevant test results prior to catheterization
Echocardiogram revealed systolic anterior motion of mitral valve and it associated with the obstruction in left ventricular (LV) outflow and mid-ventricular obstruction (peak pressure gradient was 184 mmHg).
Relevant catheterization findings
Coronary angiogram showed no narrowing of major epicardial coronary arteries. The left ventriculography showed a hyperkinetic contraction pattern at the mid-ventricule with a narrow muscular tunnel between LV apical and basal cavity.
Because of re fractoriness for medication, we planned a percutaneous transluminal septal ablation (PTSMA). Before PTSMA procedure, coronary computed tomographic angiography (CCTA) was performed to clarify the positional relation between septal branches (SB) and LV septum which caused outflow obstruction. CCTA showed distal branch of first major SB and proximal branch of second SB were distributed at the obstructive LV septum, and these findings assured us that the ablation for these branches should be effective in decreasing intraventricular pressure gradient. After wiring to the target SB, an over the wire balloon catheter of 1.5 x 6 mm was placed in the proximal part of these SBs. After verified by contrast echocardiography, we injected 3.5 ml absolute ethanol (first SB 2.5 ml and second SB 1ml) with the speed of 1 ml/min through balloon catheter. After ethanol injection, hemodynamic measurements demonstrated significant reduction in mean intraventricular pressure gradient (140 mmHg to 80 mmHg). Creatine kinase rose up to 1952 IU/dL with a MB fraction 357 IU/dL, but any complications were not seen during the hospitalization. At one month later, echocardiogram revealed significant reduction of LV outflow pressure gradient was still maintained (184 mmHg to 48 mmHg).
SB distribution is often highly-diverse, therefore, it's sometimes very difficult to detect which SB is the best target branch with angiography alone. CCTA gives us useful morphological information about positional relation between SB distribution and LV septum and enables to perform more effective and safer ablation in PTSMA procedure.