“Protruding Myocardium” as a Target for Percutaneous Transluminal Septal Myocardial Ablation in a Case of Hypertrophic Obstructive Cardiomyopathy

JACC: CARDIOVASCULAR INTERVENTIONS

VOL. 8, NO. 12, 2015

ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

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http://dx.doi.org/10.1016/j.jcin.2015.05.029

IMAGES IN INTERVENTION

“Protruding Myocardium” as a Target for Percutaneous Transluminal Septal Myocardial Ablation in a Case of Hypertrophic Obstructive Cardiomyopathy Yuichiro Maekawa, MD, PHD,* Keitaro Akita, MD,* Hikaru Tsuruta, MD,* Fumiaki Yashima, MD,* Mai Kimura, MD,* Yoshitake Yamada, MD, PHD,y Takashi Kawakami, MD,* Hideaki Kanazawa, MD, PHD,* Kentaro Hayashida, MD, PHD,* Shinsuke Yuasa, MD, PHD,* Mitsushige Murata, MD, PHD,* Masahiro Jinzaki, MD, PHD,y Keiichi Fukuda, MD, PHD*

A

57-year-old woman with known hypertrophic

ablation was performed in the first branch of

obstructive cardiomyopathy (HOCM) pre-

the identified target vessels guided by real-time

sented with dyspnea and fatigue, consistent

2-dimensional echocardiography to the enhanced

with New York Heart Association (NYHA) functional

saturation of each vascular bed (Figure 1C). The

class III heart failure. The patient had previously

post-procedural LVOT gradient was 7 mm Hg. Three

undergone percutaneous transluminal myocardial

months later, her symptoms improved to NYHA func-

ablation (PTSMA) twice at another hospital. Echocar-

tional class I, and echocardiography revealed the “protruding

diography revealed a “protruding myocardium,” sys-

disappearance

tolic anterior motion of the mitral valve, and mild

(Figure 1D, Online Video 3). Target vessel selection is

of

the

myocardium”

mitral regurgitation (Figures 1A and 1B, Online

the most important step in PTSMA (1). Misidentifica-

Videos 1 and 2). The “protruding myocardium”

tion of the correct target vessel is a potential cause

adjoined the basal and mid-portion of the ventricular

of PTSMA failure. In addition, the guidewire can occa-

myocardium that had been previously ablated. At

sionally fail to pass due to technical difficulties

rest,

(LVOT)

despite correct identification of the target septal

gradient was 109 mm Hg. Comparison of the coro-

branches. Our case highlights the importance of target

nary angiography that we performed with that per-

vessel selection and complete myocardial ablation.

the

left

ventricular

outflow

tract

formed previously at another hospital confirmed that 1 of the 2 proximal septal branches could not

REPRINT REQUESTS AND CORRESPONDENCE: Dr.

be used in PTSMA because the guidewire could

Yuichiro Maekawa, Department of Cardiology, Keio Uni-

not be passed. The patient declined open surgery;

versity School of Medicine, Shinanomachi 35, Shinjuku-ku,

therefore, PTSMA was performed. Selective alcohol

Tokyo 160-8582, Japan. E-mail: [email protected].

From the *Department of Cardiology, Keio University School of Medicine, Tokyo, Japan; and the yDepartment of Diagnostic Radiology, Keio University School of Medicine, Tokyo, Japan. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received May 7, 2015; accepted May 23, 2015.

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Maekawa et al.

JACC: CARDIOVASCULAR INTERVENTIONS VOL. 8, NO. 12, 2015

“Protruding Myocardium” as a Target for PTSMA in a Case of HOCM

OCTOBER 2015:e201–2

F I G U R E 1 Transthoracic Echocardiographic Images and Coronary Angiogram

Two-dimensional (A, Online Video 1) and color Doppler (B, Online Video 2) images of the parasternal long-axis view demonstrating systolic anterior motion of the mitral valve, mild mitral regurgitation, and a “protruding myocardium” (white arrow). (C) Coronary angiogram of the right anterior oblique cranial projection showing the first septal branch of the identified target vessels (white arrows). (D, Online Video 3) Twodimensional image of the parasternal long-axis view taken 3 months after percutaneous transluminal myocardial ablation demonstrating the disappearance of the ablated “protruding myocardium.” Ao ¼ aorta; LA ¼ left atrium; LV ¼ left ventricle.

REFERENCE 1. Maekawa Y, Jinzaki M, Anzai A, et al. Successful second attempt multidetector computed tomography-guided percutaneous transluminal septal myocardial ablation for an octogenarian with hypertrophic obstructive cardiomyopathy. Int J Cardiol 2014;176:e131–2.

KEY WORDS heart failure, hypertrophic obstructive cardiomyopathy, percutaneous

AP PE NDIX For the accompanying videos, please see the online version of this

transluminal septal myocardial ablation

article.