Treatment of hypertrophic obstructive cardiomyopathy with alcohol ablation

Kulić M., Spužić M., Tahirović E.,Mujačić V., Šošević A., Perva O.,

Ćibo M., Zorman D.*

Centar za srce, KCU Sarajevo *Univerzitetni klinični center Ljubljana

V Congress of Cardiologists BiH with international participation, Radon Plaza, Sarajevo , 27-29 may, 2010.

Def. Hypertrophic obstructive cardiomyopathy

– primary genetic cardiac disorder, characterized with

massive myocardial hypertrophy, with dynamic left ventricular

outflow tract obstruction and diastolic dysfunction

of the left ventricle.

Kulić M, Spužić M, Tahirović E et al. Treatment of HOCM with alcohol ablation

Symptoms:

Angina,

Dyspnea,

Syncope,

Uncomfortable awareness of the heart beat (palpitations).

Kulić M, Spužić M, Tahirović E et al. Treatment of HOCM with alcohol ablation

Treatment:

Medicamention;

Surgical myectomy;

Ventricular pacing;

Alcohol septal ablation – PTSMA* (Sigwart method)

*PTSMA - percutaneous transluminal septal myocardial ablation

Kulić M, Spužić M, Tahirović E et al. Treatment of HOCM with alcohol ablation

Nishimura R. and Holmes D. NEJM 2004 350:1320

Kulić M, Spužić M, Tahirović E et al. Treatment of HOCM with alcohol ablation

Number of patient (n) 4 Sex M/F 0/4 Age (years) (range) 44.75±23.45;

43 (24-67) Symptoms Dyspnea on effort 4 Syncope 1 Angina pectoris 1 Heart rhythm disorders before PTSMA (Pace-maker)

-

Medicament Beta blockers 4 Aspirin ACE- inhibitor Ca-blockers ISMN

2 2 1 1

Coronary heart disease Hypertension

1 2

Surgical myectomy 1

Kulić M, Spužić M, Tahirović E et al. Treatment of HOCM with alcohol ablation

Table 1. Characteristicsof patients before PTSMA

Table 2. Echocardiographic parameters before and after PTSMA

Before PTSMA

After PTSMA

(3 months)

p

Number of patients (n) 4 4 Pressure gradient (mmHg) 92.5±16.4 36.5±17.3 0.0017 IVSd thickness (mm) 26.8±4.03 23.3±4.35 0.41 LVPWd thickness (mm) 16.5±1.29 15.5±0.57 0.1035 LV EF (%) 64.75±4.11 62.25±7.78 0.3257 MR 2.33±0.57 1.33±0.57 0.05 p<0.01

Kulić M, Spužić M, Tahirović E et al. Treatment of HOCM with alcohol ablation

Table 3. Characteristics of PTSMA

Number of patients (n) 4 Number of occluded septal braches S1 2 S1+S2 2 Volume of ethanol infused per patient (ml) 3 Heart rhythm disorders (bradycardia, AV block gr. II, AV block gr.III, VES,VT,VF)

2

Kulić M, Spužić M, Tahirović E et al. Treatment of HOCM with alcohol ablation

Female patient 33 years old,Female patient 33 years old,

She was taken to Neurological Clinic because of syncope She was taken to Neurological Clinic because of syncope and family history of epilepsy.and family history of epilepsy.

After few weeks of treatment with antiepileptic, After few weeks of treatment with antiepileptic, she had againshe had again dyspnea dyspnea, syncopes and , syncopes and NYHA IV.NYHA IV.

ECHO IVSs 28mm, LVPWs 22mm, SAM, ECHO IVSs 28mm, LVPWs 22mm, SAM, LVOTPG mLVOTPG maxax 85mmHG, MR moderate, TRPGmax 85mmHG, MR moderate, TRPGmax 35mmHg.35mmHg.

EECCG – HLV, without of heart rhythm disorders.G – HLV, without of heart rhythm disorders.

Kulić M, Spužić M, Tahirović E et al. Treatment of HOCM with alcohol ablation

CASE REPORT

Started medication therapy Started medication therapy (high doses of Beta-blockers – metoprolol) – unsuccessful !(high doses of Beta-blockers – metoprolol) – unsuccessful !

Surgical myectomy – (Surgical myectomy – (Morrow method)Morrow method), four years after , four years after surgical myectomy without symptoms!surgical myectomy without symptoms!

After four years again same symptoms like as dyspnea After four years again same symptoms like as dyspnea angina, syncope episodes.angina, syncope episodes.

ECHO IVSECHO IVSdd 26mm (on the place surgical myectomy), 26mm (on the place surgical myectomy), LVOTPG mean 49mmHg, SAM, MR moderate.LVOTPG mean 49mmHg, SAM, MR moderate.

Alcohol septal ablation – (Alcohol septal ablation – (Sigwart method)Sigwart method)..

Kulić M, Spužić M, Tahirović E et al. Treatment of HOCM with alcohol ablation

Figure 1. (Left above) Parasternal long-axis view, thickness IVSd 26mm, arrow shows place of the septal myectomy. (Right above) Parameters before PTSMA. (Left down) PTSMA the second septal artery. (Right down) Parameters after PTSMA.

Figure 2. Different in hemodynamic values before and after PTSMA.

A. Ao S/D/M 80/43/61 – LV S/D/M 179/11/27 B. Ao S/D/M 145/14/15 - LV S/D/M 117/65/88

Kulić M, Spužić M, Tahirović E et al. Treatment of HOCM with alcohol ablation

HEMODYNAMIC DATA

PTSMA video

Kulić M, Spužić M, Tahirović E et al. Treatment of HOCM with alcohol ablation

Kulić M, Spužić M, Tahirović E et al. Treatment of HOCM with alcohol ablation

Conclusions Invasive cardiology method,

Provides symptomatic relief,

Leads to hemodynamic improvement,

Refractory on medication therapy,

Unsuccessful surgical myectomy.

Thank you for your attention, Greetings from ”Department of Invasive Cardiology - Heart centre Sarajevo”!