Abstract
We report the case of a patient with severe malignant hypertrophic obstructive cardiomyopathy (HOCM) and calcified stenosis of the proximal and middle left anterior descending (LAD) coronary artery. We elected to treat his ischemic heart disease first. We performed angioplasty of the proximal and middle LAD, after rotative atherectomy, and implanted two bare metal stents. Thirty days later we treated his HOCM by alcohol septal ablation with catheterization of the first septal branch through the mesh of the bare metal stent implanted in the LAD. To our knowledge, this is the first documented report of such a procedure.
1
Introduction
Alcohol septal ablation has become a standard alternative technique to surgery (septal myomectomy or myotomy) in the second line treatment of symptomatic HOCM after failure of drug therapy. It is not uncommon for patients with HOCM to have coronary lesions in particular in the LAD, which require surgical revascularization or percutaneous angioplasty. What policy should be adopted concerning revascularization of the LAD in patients who are scheduled to have alcohol septal ablation? There is one documented report of alcohol septal ablation immediately followed by angioplasty with stent implantation in the LAD . We report the first case of alcohol septal ablation performed after angioplasty through the mesh of a bare metal stent implanted in the LAD after rotary atherectomy.
2
Case report
The patient was a 67-year-old man with hypertension and dyslipidemia who had been diagnosed with HOCM in 1993. Ultrasound showed a left ventricular outflow tract pressure gradient (LVOTPG) of 30 mmHg under treatment with effective beta-blocker dose. His heart disease was considered stable under treatment. He was also receiving oral anticoagulation for paroxysmal atrial fibrillation.
In the aftermath of complicated digestive surgery, he developed acute coronary syndrome (ACS) without ST elevation and with elevated troponin. The patient was admitted to our cardiology department with New York Heart Association (NYHA) functional class III. On auscultation, he had a systolic ejection murmur. Transthoracic echocardiography (TTE) showed an ejection fraction of 51%. The patient had asymmetric hypertrophy confined to the basal ventricular septum (measuring 28 mm in thickness) with significant intra left ventricular dynamic obstruction at rest (peak LVOTPG was 137 mmHg ( Fig. 1 )) and systolic anterior motion (SAM) of the mitral valve that was causing moderate mitral regurgitation ( Fig. 1 ). Angiographic assessment showed a tortuous tight stenosis of the proximal LAD at the origin of the first three septal branches ( Fig. 2 A ). The lesion extended up to the middle segment of the LAD. It was critical at the septal branches and strongly calcified. No significant stenosis was observed in the rest of the coronary network.
It was decided to treat this proximal lesion by angioplasty.
A first attempt at revascularization by conventional angioplasty was unsuccessful: the lesion was resistant to inflation of a non-compliant balloon 3 mm inflated to 25 atm ( Fig. 2 B). We then performed rotative atherectomy (Rotablator ®: burr size 2 mm in diameter) ( Fig. 3 A ) to allow the implantation of a bare metal stent of 3.5 mm × 18 mm ( Fig. 3 B), which covered the ostium of the first septal branches. The second lesion was pre-dilated and implanted with a second bare metal stent (2.75 mm × 18 mm).
A month later, the patient remained symptomatic (NYHA functional class III) under optimal drug treatment. Given the persistence of LVOTPG, we elected to perform alcohol septal ablation. After placement of a catheter for temporary transvenous ventricular pacing, the first septal branches were catheterized through the mesh of the stent implanted a month earlier. Ultrasound contrast determined whether the septal region to be treated corresponded to the territory vascularized by the first two parts of the bouquet. After placement of an occlusion balloon, 2 ml of alcohol was injected downstream of the balloon at the first two branches ( Fig. 4 B ). Ten minutes after rinsing, the balloon was removed and there was a no-flow in two of the three branches of the septal bouquet ( Fig. 4 C). Ultrasound showed an immediate reduction of the LVOTPG ( Fig. 5 ) and mitral regurgitation.
