Author + information
- Yuichiro Maekawa1
Patient initials or identifier number
Relevant clinical history and physical exam
A 63 year-old man complained of exertional dyspnea 5 years ago. He had a check-up at the family doctor and then was diagnosed with the hypertrophic obstructive cardiomyopathy after echocardiography was performed. His symptoms gradually worsened under treatment with bisoprolol. Exertional dyspnea of recent 2 years duration was refractory to maximal medical therapy. The murmur at medial to the apex is grade 3/6 in intensity, with radiation to the left sternal border and axilla.
Relevant test results prior to catheterization
Electrocardiography on admission showed V5-6 high voltage suggesting left ventricular hypertrophy. Cardiac enlargement was showed on chest X-ray. Echocardiography revealed asymmetric septal hypertrophy, a left ventricular outflow tract systolic gradient of 115 mm Hg, systolic anterior motion of the mitral valve, and moderate mitral valve regurgitation. Cardiac magnetic resonance imaging showed absence of late gadolinium enhancement. His plasma B type natriuretic peptide level was 386 pg/mL.
Relevant catheterization findings
The Left and right heart catheterization was performed to evaluate her hemodynamics. Right heart catheterization showed a mean pulmonary artery pressure of 30 mmHg and mean pulmonary capillary wedge pressure of 24 mmHg. There was a left ventricular outflow tract (LVOT) gradient of 122 mmHg at rest and 140 mmHg provoked by the Valsalva maneuver. Coronary angiography confirmed three proximal septal branches of the left anterior descending coronary artery.
A 6Fr femoral arterial sheath inserted for the guide catheter system, and a 5Fr radial sheath was inserted for pigtail catheter placement into the LV cavity. A septal perforating artery supplying the obstructing part of the septum was identified on the coronary angiogram, and chosen as the target vessel. The guide wire easily passed into a proximal two major septal branch using the “Antegrade approach”, and transcoronary injection of absolute alcohol was performed. However, the LVOT gradient following the procedure remained high. Next, we attempted to pass the guide wire into the “third” septal branch using “Antegrade approach”, but failed. Therefore, we subsequently used the “retrograde approach“ with the “reverse wire technique” . In the reverse wire technique, XT-R wire and crusade catheter, a double-lumen multi functional probing micro catheter, were used. The guide wire crossing into a highly angulated septal branch was easily achieved using the reverse wire technique, which involves making a reverse bend in the coronary guide wire about 3 cm from its distal tip. After advancing the guide wire using a Crusade in the distal main vessel, the Crusade micro catheter is pulled back proximally,and the guide wire is manually steered back into the septal branch with some rotation. Finally, absolute ethanol ablation was successfully performed, resulting in the LVOT gradient decreasing to 6 mm Hg after the procedure. No significant complications occurred.
Based on our experience, we believe that the “Reverse wire technique” may be useful for angled septal branch wiring in alcohol septal ablation, and we reported a case of septal branch wiring using the reverse wire technique for alcohol septal ablation in a drug-refractory symptomatic hypertrophic obstructive cardiomyopathy.