30/12/2017
Effective treatment of hypertrophic cardiomyopathy
Mr. R, a 57 years old male has come to Indo US Hospital, Hyderabad with recent onset of breathlessness on exertion NYHA class II. He gave history of atypical chest pain for about six months. There was history of near syncope on exertion twice in the last 6 months. He is a diabetic for the last 15 years but did not give history of Hypertension. He is a non-smoker and Teetotaler.
He was evaluated at Nellore and was diagnosed as a case of hypertrophic cardiomyopathy and was advised to undergo alcohol septal ablation for which he was referred to us. His physical examination showed a prominent LV type of apex with palpable S4. There is a systolic murmur of 2/6 at left sternal edge. His BP was 130/80 mm/Hg, heart rate 84/min. There were no sign of heart failure. His electrocardiogram showed RBBB with left atrial enlargement. chest x-ray showed mild
cardiac enlargement. Echo showed severe hypertrophy of left ventricle which was assymmetric indicating that the intra ventricular septum hypertrophy is more than that of the posterior wall (unlike simple hypertension where the hypertrophy is symmetric).
The IVS thickness was 19 mm and PW thickness was 15 mm. There was SAM (systolic anterior motion) of the AML (anterior mitral leaflet). There was a gradient of 140 mm in the out flow tract of LV, due to obstruction just below the aortic valve produced by SAM. There was mild mitral regurgitation. With this data it was quite clear that we are dealing with a case of severe HOCM. In view of his symptoms, we decided to do Alcohol septal ablation. Coronary angio showed normal coronaries. The LAD has a large septal artery which is conducive to alcohol septal ablation. The septal artery has been wired and a 1.5
mm over the wire balloon was passed into the septal artery and the balloon was inflated.
The wire was then removed and 100% (absolute) alcohol was injected at 0.5 ml at one time to a total of 2.0 ml. The gradient has come down markedly in the next few minutes. The whole procedure was done under echocardiographic guidance. A temporary pacing wire was kept starting from the beginning of
the procedure till 48 hours because there is a small risk of complete heart block. No adverse effects occurred in our patient and he recovered uneventfully with nil gradients at the end of the procedure.