Emergency Alcohol Septal Ablation for Cardiogenic Shock in Obstructive Hypertrophic Cardiomyopathy

Figures

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  Visual Summary. Timeline of Events

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  Figure 1. Transesophageal Echocardiography Before Alcohol Septal Ablation (A) Severe left ventricular outflow tract (LVOT) obstruction with a peak gradient of 107 mm Hg; a characteristic dagger-shaped appearance is demonstrated. (B) Systolic anterior motion of the anterior mitral valve leaflet (red arrow) is noted, along with moderate-to-severe mitral regurgitation (yellow arrow). Ao = aorta; LA = left atrium; LV = left ventricle.

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  Figure 2. Equipment List ASA = alcohol septal ablation; HCM = hypertrophic cardiomyopathy; LVOTO = left ventricular outflow tract obstruction.

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  Figure 3. Catheter Tracing Before and After Alcohol Septal Ablation (A) Hemodynamic tracing before alcohol septal ablation demonstrates systemic hypotension (63/41 mm Hg) with pronounced postextrasystolic augmentation in the left ventricular outflow tract gradient (from 172 mm Hg to 207 mm Hg), confirming severe left ventricular outflow tract obstruction. (B) Post–alcohol septal ablation tracing (15 minutes later) shows improved systemic blood pressure (>120/70 mm Hg) and resolution of left ventricular outflow tract obstruction.

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  Figure 4. Angiography (A) An angiogram shows localization of the second septal perforator with transesophageal echocardiographic guidance. (B) Angiography after alcohol septal ablation confirms the successful occlusion of the septal perforator injected with isopropyl alcohol.

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  Figure 5. Intraprocedural Echocardiography (A) Intraoperative transesophageal echocardiographic image before alcohol septal ablation shows systolic anterior motion of the anterior mitral valve leaflet (AMVL) and moderate mitral regurgitation. (B) Intraoperative transesophageal echocardiographic image after alcohol septal ablation demonstrates resolution of systolic anterior motion of the AMVL and reduction of mitral regurgitation to mild. Ao = aorta; LA = left atrium; LV = left ventricle; LVOT = LV outflow tract.

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  Figure 6. Transthoracic Echocardiography Findings 1 Week After Alcohol Septal Ablation Transthoracic echocardiography 1 week after alcohol septal ablation demonstrates the resurfacing of LVOT obstruction (A) at rest (134 mm Hg) and (B) with the Valsalva maneuver (165 mm Hg), along with (C) chordal SAM (yellow arrow) of the mitral valve on M-mode. LVOT = left ventricular outflow tract; SAM = systolic anterior motion.

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  Figure 7. Transthoracic Echocardiography at 3-Month Follow-Up Outpatient transthoracic echocardiography at 3 months after the procedure shows no significant left ventricular outflow tract gradient (A) at rest (7 mm Hg) or (B) with the Valsalva maneuver (5 mm Hg). LVOT = left ventricular outflow tract.