shu-508 and Cardiomyopathy--Hypertrophic

Myocardial contrast echocardiography guided alcohol septal ablation (PTSMA) is an established treatment for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). Most important properties of the optimal echocardiographic contrast agent are good contrast imaging and sufficient stability without fast washing out. HOCM was diagnosed in a 49-year-old female patient 4 years before first admission. Despite optimal medical treatment the patient was highly symptomatic with angina pectoris and dyspnoea NYHA II-III.Investigations, treatment and course: ECG showed signs of left ventricular hypertrophy. Echocardiography revealed asymmetric septal hypertrophy, dynamic LVOT obstruction with pronounced SAM and associated moderate mitral valve regurgitation. Coronary angiography performed in the catheterization laboratory showed coronary atherosclerosis and haemodynamic measurements verified a significant LVOT obstruction. An atypical septal branch, originating from the intermediate artery, was regarded as target branch and was occluded with a balloon catheter. For the contrast echocardiography guided septal ablation cold, agitated Gelafundin® was used. This led to a good subaortic septal contrast demarcation with confirmation of the correct choice of target branch. No arrhythmias were recorded during the administration of contrast medium. Injection of Levovist® in the same septal branch for comparison resulted in opacification of the same myocardial area without any sign of misplacement. After alcohol injection in the balloon-occluded septal branch, an effective elimination of the LVOT gradient could be haemodynamically documented.. For contrast echocardiography guided PTSMA a good myocardial opacification with an appropriate contrast agent is essential, not only to recognize the obstruction dependent region but also to identify any possible misplacement. Gelafundin® seems to offer similarly sufficient contrast potential as Levovist®, so that Gelafundin® could be a possible alternative.

Topics: Cardiac Catheterization; Cardiomyopathy, Hypertrophic; Contrast Media; Echocardiography; Ethanol; Heart Septum; Humans; Polygeline; Polysaccharides; Ultrasonography, Interventional

Several methods are used to induce latent left ventricular outflow tract (LVOT) gradients in patients with hypertrophic cardiomyopathy (HCM). We compared LVOT gradients induced by Valsalva manoeuvre (VM) and exercise echocardiography (EE) in patients with HCM treated with percutaneous transluminal septal myocardial ablation (PTSMA).. Left ventricular outflow tract gradients were measured at rest, during VM, and during EE in 57 patients 3.8 ± 2.8 years after PTSMA. Measurement succeeded in all patients during VM and in 96% during EE. There were no differences in LVOT gradients between VM [17 (9-33) mmHg] and EE [18 (10-30) mmHg, P = 0.31] [median (inter-quartile range)], but the differences ranged from -45 to 84 mmHg in individual patients. In 93% of patients, EE had no influence on the categorization into manifest-, latent- or non-obstructive phenotypes. The 7%, who revealed LVOT gradients ≥30 mmHg only during EE, did not reach LVOT gradients of 50 mmHg. Patients improving two New York Heart Association (NYHA) classes after PTSMA had higher baseline LVOT gradients during VM [115 (72-160) vs. 88 (54-114) mmHg, P = 0.04] and a larger reduction in VM-induced LVOT gradients [80 (48-139) vs. 61 (28-83) mmHg, P = 0.02] than patients improving one NYHA class.. Valsalva manoeuvre and EE induce similar degrees of LVOT gradient, but categorization into obstructive phenotypes was not influenced by EE in more than 90% of patients. Valsalva manoeuvre should be the primary choice of stress modality in HCM patients treated with PTSMA, but EE is essential for the clinical management of the entire cohort.

Topics: Analysis of Variance; Cardiomyopathy, Hypertrophic; Catheter Ablation; Chi-Square Distribution; Cohort Studies; Contrast Media; Echocardiography, Doppler; Echocardiography, Stress; Female; Humans; Male; Middle Aged; Polysaccharides; Statistics, Nonparametric; Treatment Outcome; Ultrasonography, Interventional; Valsalva Maneuver; Ventricular Outflow Obstruction

To provide tools for predicting the course of AV conduction disturbances after ethanol-induced septal ablation (PTSMA) for hypertrophic obstructive cardiomyopathy (HOCM).. Based on a scoring system developed 1996-1998 and including parameters from baseline ECG, heart rate profile, severity of outflow obstruction (LVOTO), peri-interventional enzyme kinetics, and peri-interventional conduction problems, the risk of permanent AV block following PTSMA was assessed in 155 consecutive HOCM patients (pts.; mean age: 53+/-13 years) between 1999 and 2004. During PTSMA with 2.1+/-0.5 ml of ethanol, transient complete AV block occurred in 71 pts. (46%). Pts. were grouped into a low, intermediate, and high risk group for permanent conduction damage, and treated accordingly (early discharge from monitoring, prolonged monitoring, early DDD-PM implantation). Permanent pacing was necessary in 11 cases (7%), 0/116 of these (0%) in the low, 4/31 (13%) in the intermediate, and 7/8 (87%) in the high-risk group. While a new right bundle branch block was the most frequent ECG finding after PTSMA, a left bundle branch block at baseline was associated with 4 of the 11 DDD-PM implantations (p<0.0001). In-hospital mortality was 0%, short-term (3-months) follow up was complete. During follow-up, AV conduction recovered in 4 pts. (46%) with a DDD-PM. New onset AV blocks did not occur. Significant improvement of symptoms was reported by 141 pts. (91%).. Catheter-based septal ablation is an effective non-surgical technique for reducing symptoms and outflow gradients in HOCM. The proposed scoring system appears to reliably discriminate pts. with a high risk for permanent PM dependency from those with stable AV conduction after PTSMA. Pts. with left bundle branch block at baseline should undergo DDD-PM implantation prior to ablation.

Topics: Analysis of Variance; Cardiomyopathy, Hypertrophic; Contrast Media; Echocardiography, Doppler; Ethanol; Female; Heart Block; Heart Septum; Humans; Logistic Models; Male; Middle Aged; Polysaccharides; Risk Factors; Treatment Outcome

The aim of this study was to evaluate the longterm follow-up results of percutaneous transluminal septal myocardial ablation (PTSMA) in a large patient cohort.. PTSMA by alcohol injection into septal branches has shown good acute and short-term results in symptomatic patients with hypertrophic obstructive cardiomyopathy.. A total of 100 consecutive symptomatic (NYHA class 2.8 +/- 0.6) patients underwent PTSMA. All patients had clinical and non-invasive follow-up at 3 months, 1 year, and annually up to 8 years.. One patient died at day 2 after intervention due to fulminant pulmonary embolism following deep venous thrombosis, and eight patients required a permanent DDD-pacemaker due to post-interventional complete heart block. Acute reduction of the left ventricular outflow tract gradient was achieved from 76 +/- 37 to 19 +/- 21 mmHg at rest, from 104 +/- 34 to 43 +/- 31 mmHg during Valsalva maneuver, and from 146 +/- 45 to 59 +/- 42 mmHg post extrasystole (p < 0.0001, each). During follow-up (mean follow-up time: 58 +/- 14 months), three additional patients died (sudden death at 48 months, non-cardiac death at 49 months and stroke-related death at 60 months after the index procedure). All living patients showed clinical improvement to NYHA-class 1.4 +/- 0.6 (after 3 months, n = 99), 1.5 +/- 0.6 (after 1 year, n = 99), and 1.6 +/- 0.7 at final follow-up (n = 96; p < 0.0001, each). Non-invasive follow-up studies documented ongoing outflow tract gradient reduction, decrease of septal and left ventricular posterior wall thickness, and improvement of exercise capacity.. PTSMA is an effective treatment for symptomatic patients with hypertrophic obstructive cardiomyopathy. Follow-up showed ongoing hemodynamic and clinical improvement without increased mortality and morbidity.

Topics: Cardiomyopathy, Hypertrophic; Chi-Square Distribution; Contrast Media; Echocardiography, Doppler; Ethanol; Exercise Test; Female; Follow-Up Studies; Heart Septum; Hemodynamics; Humans; Male; Middle Aged; Polysaccharides; Solvents; Survival Analysis; Treatment Outcome; Ventricular Outflow Obstruction

To analyze the impact of intra-procedural echocardiographic imaging on the interventional strategy in ethanol-induced septal ablation (PTSMA) for symptomatic hypertrophic obstructive cardiomyopathy (HOCM), based on a single-center experience of 7 years.. PTSMA was intended for refractory symptoms in 337 patients (pts.) with HOCM (mean age: 54 +/- 15 years), with 312 procedures completed by injection of 2.8 +/- 1.2 ml ethanol. In 25 pts. (8%) the intervention was aborted without ethanol injection, mostly because of echocardiographic findings (n = 18/6%). An echocardiography-driven target vessel change was necessary in 33 pts. (11%). In the 312 pts. who received ethanol, permanent pacing was necessary in 22 cases (7%). In-hospital mortality was 1.3% (4 pts.). After 3 months, mean NYHA functional class was reduced from 2.9 +/- 0.5 to 1.5 +/- 0.6 (p < 0.0001) along with a gradient reduction from 60 +/- 33 to 13 +/- 18 mmHg at rest, and from 120 +/- 43 to 38 +/- 35 mmHg with provocation (p < 0.0001 each). Exercise capacity improved from 94 +/- 51 to 115 +/- 43 W, peak oxygen consumption from 18 +/- 4 to 21 +/- 6 ml/kg/min (p < 0.01 each). There was no significant difference regarding residual gradients in pts. with different levels of immediate gradient reduction during probatory balloon occlusion.. Catheter-based septal ablation is an effective non-surgical technique for reducing symptoms and outflow gradients in HOCM. Intra-procedural echocardiographic guidance has a cumulative impact on the interventional strategy in about 15-20%, and clearly identifies pts. who should not receive ethanol but undergo a surgical myectomy.

Topics: Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Cardiac Catheterization; Cardiomyopathy, Hypertrophic; Chemoembolization, Therapeutic; Contrast Media; Echocardiography; Ethanol; Female; Heart Septum; Humans; Male; Middle Aged; Polysaccharides; Treatment Outcome; Ultrasonography, Interventional; Ventricular Outflow Obstruction

Patients with electrocardiography (ECG) abnormalities sometimes present without obvious symptoms or abnormal physical findings. In some cases, echocardiography fails to reveal abnormalities compatible with the ECG findings because of poor echocardiographic image quality. New intravenous contrast agents now enable opacification of the left ventricular cavity in the clinical setting. The usefulness of left ventricular opacification (LVO) by ultrasonic contrast agent was examined in asymptomatic patients with negative T waves on ECG.. Thirty-four consecutive patients (23 males, 11 females, mean age 68 +/- 10 years) with negative T waves without symptoms or abnormal physical findings underwent routine transthoracic echocardiography and LVO by intravenous injection of Levovist using harmonic imaging.. Without LVO, abnormal echocardiographic findings compatible with the negative T waves were identified in 22 (65%) of the 34 patients. With LVO, the endocardial border of the left ventricle was observed in all patients and findings compatible with negative T waves were detected in 32 (94%) of the 34 patients, which was significantly higher than that without LVO (chi 2 = 9.79, p = 0.0055). Furthermore, LVO revealed additional findings in nine patients such as mural thrombus or apical thinning. In total, LVO revealed abnormal apical findings in 22 patients (65%), which was significantly higher than that without LVO (chi 2 = 10.0, p = 0.0013).. LVO is useful for identifying abnormal findings, especially in the apex in asymptomatic patients with negative T waves on ECG.

Topics: Aged; Cardiomyopathy, Hypertrophic; Contrast Media; Echocardiography; Electrocardiography; Female; Heart Ventricles; Humans; Male; Middle Aged; Myocardial Contraction; Polysaccharides

Topics: Cardiomyopathy, Hypertrophic; Catheter Ablation; Contrast Media; Coronary Vessels; Echocardiography; Female; Humans; Middle Aged; Polysaccharides

Percutaneous septal ablation has evolved as an alternative to surgery for reducing symptoms and outflow gradients in patients with hypertrophic obstructive cardiomyopathy. Intraprocedural echo-cardiographic imaging can improve clinical and hemodynamic results. Growing experience with this method has additionally shown that threatening necrosis of the myocardium distant from the septal target region can be detected.. Percutaneous septal ablation was performed in 162 patients (80 women, 82 men; aged 54.1 +/- 15.5 years); 131 of whom were targeted by intraprocedural myocardial contrast echocardiography. In 11 patients (7%), an atypical target vessel or a perfusion area distant from the expected septal target region was detected, leading to a target vessel change. Permanent pacing was necessary in 14 patients (9%). Three patients (2%) died. After 3 months, the mean New York Heart Association functional class was reduced in the returning 159 patients from 2.8 +/- 0.5 to 1.3 +/- 1.0 (P <.0001) along with a gradient reduction from 77 +/- 35 to 12 +/- 22 mm Hg at rest, and from 147 +/- 43 to 44 +/- 45 mm Hg with provocation (P < .0001 each). The main reason for unsatisfactory gradient reduction was suboptimal scar placement in the patients treated before the introduction of intraprocedural myocardial contrast echocardiography.. Percutaneous septal ablation is an effective nonsurgical technique for reducing symptoms and outflow gradients in hypertrophic obstructive cardio-myopathy. Echocardiographic guidance adds substantially to safety and efficacy of the procedure and should therefore be considered routinely.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cardiomyopathy, Hypertrophic; Catheter Ablation; Chi-Square Distribution; Contrast Media; Echocardiography; Ethanol; Female; Humans; Male; Middle Aged; Monitoring, Intraoperative; Polysaccharides; Postoperative Complications; Treatment Outcome; Ventricular Outflow Obstruction