A Road Less Traveled: Successful Alcohol Septal Ablation via an Aberrant Septal Coronary Artery in Hypertrophic Obstructive Cardiomyopathy

Figures

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  Figure 1. Electrocardiograms: (A) Pre‐procedure baseline 12‐lead ECG demonstrating sinus bradycardia with a heart rate of 51 beats per minute with left ventricular hypertrophy. (B) Post‐procedure 12‐lead ECG demonstrating sinus bradycardia at 49 beats per minute and a new right bundle branch block. [Color figure can be viewed at wileyonlinelibrary.com]

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  Figure 2. Transthoracic echocardiography: (A) Pre‐procedural echocardiogram with parasternal long axis view demonstrating septal thickness of 17.9 mm (yellow line). (B) Intraprocedural echocardiography during contrast injection confirms contrast localization to the target basal septum (red arrow) from the engaged coronary branch and exclusion of intracardiac contrast delivery. (C) Pre‐procedure echocardiography continuous wave Doppler profile demonstrating typical LVOT obstruction with “dagger‐shaped” envelope (yellow box) and a peak gradient of 70 mmHg with Valsalva. (D) Pre‐procedure echocardiography M‐mode through the mitral valve demonstrating septal systolic anterior motion (blue arrow). [Color figure can be viewed at wileyonlinelibrary.com]

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  Figure 3. Baseline coronary angiography: (A) LAO‐caudal and (B) RAO‐caudal projection demonstrating the target septal branch (red arrow) originating from the ramus intermedius. (C) A 6 French JL4 guide catheter was used to engage the left coronary artery, and a Fielder XT coronary wire was advanced to this septal branch (red arrow). (D) A 2.0 × 8 mm over‐the‐wire balloon (red arrow) positioned in this septal branch and inflated to 2 atm for the remainder of the procedure. [Color figure can be viewed at wileyonlinelibrary.com]

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  Figure 4. Pre/post‐procedural hemodynamics: (A) Baseline pre‐procedural hemodynamics demonstrating an initial LVOT gradient of 65 mmHg. (B) Baseline pre‐procedural hemodynamics demonstrating the Brockenbrough‐Braunwald‐Morrow (BBM) sign seen in patients with HOCM. In the BBM sign, a premature ventricular contraction (PVC) occurs after which there is a compensatory pause allowing for increased LV filling time and subsequent increased LV contractility resulting in a decrease in aortic pulse pressure (vertical red double‐headed arrow) and an increase in the LVOT gradient (vertical blue doubled‐headed arrow). A classic “spike and dome” appearance (red asterisk) of the aortic pressure tracing is also observed as part of the BBM sign. The table associated with Figure 4B numerically tabulates the hemodynamic changes throughout the BBM sign. (C) Post‐procedure hemodynamics demonstrating resolution of LVOT gradient. (D) Post‐procedure hemodynamics demonstrating resolution of the BBM sign after a PVC. Dotted lines (labeled LV in blue): Left ventricular pressures; solid Lines (labeled AO in red): Aortic pressure. [Color figure can be viewed at wileyonlinelibrary.com]

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  Figure 5. Post‐procedure coronary angiography, septal branch occlusion: (A) Post‐procedural coronary angiography demonstrating complete occlusion of the septal branch (red arrow). (B) For comparison, this coronary angiogram, reproduced from reference [4], demonstrates a first septal perforator artery originating from the LAD (black arrow); this angiogram serves as an example of the desired anatomy that is ideal for ASA. [Color figure can be viewed at wileyonlinelibrary.com]

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  Central Figure 1. Algorithmic approach to septal reduction therapies for HOCM and ideal coronary anatomy for ASA: The algorithm presented here has been adapted from reference [6] “The American Journal of Cardiology, Treatment Strategies for Hypertrophic Cardiomyopathy: Alcohol Septal Ablation and Procedural Step‐by‐Step Technique.” [Color figure can be viewed at wileyonlinelibrary.com]