1 xx

IN

CASE STUDY

HYPERTROPHIC CARDIOMYOPATHY:

One Patient’s Course of TreatmentJanette LaFroscia

2 xx2 xx

CASE STUDY OVERVIEW

• Review of HCM• Characteristics• Symptoms• Treatments

• Alcohol Septal Ablation• General overview

• A Patient with HOCM

3 xx3 xx

CASE STUDY

HYPERTROPHIC CARDIOMYOPATHY

• HCM, HOCM, IHSS, ASH

• Definition: abnormal thickening of the myocardium• Typically involves the septum• Decreased LV chamber size with narrowed

LVOT• Displacement of Mitral valve

• Causes decrease in CO and BP

4 xx4 xx

CASE STUDY

HYPERTROPHIC CARDIOMYOPATHY

• Can lead to:• Dynamic LVOT obstruction• MR• Diastolic dysfunction• Myocardial ischemia• Arrhythmias: SVTs and VT/VF/SCA

5 xx5 xx

CASE STUDY

HYPERTROPHIC CARDIOMYOPATHY

• Symptoms:• Dyspnea• Fatigue• Chest pain• Dizziness• Syncope• SCA

• Diagnosed with: H&P, Echo, EKG, MRI, and/or Left Heart Catheterization

6 xx6 xx

CASE STUDY

• HYPERTROPHIC CARDIOMYOPATHY

• Treatments:• Medications- Beta Blockers, Ca Channel

Blockers, Disopyramide• Surgery- Septal myectomy• DDD PPM- force RVA pacing with

Negative AV Hysteresis (Class IIb)• ICD- SCA (Class I); positive family history,

NSVT, syncope, decreased BP with exercise, LV > 30mm (Class IIa)

• Alcohol Ablation

7 xx7 xx

CASE STUDY

ALCOHOL SEPTAL ABLATION

• Definition: a percutaneous, minimally-invasive procedure to relieve symptoms and improve QOL with severely symptomatic patients

• Introduced in 1994

• Creates a small, controlled MI• Damages the area causing obstruction, leading to

an more opened LVOT and improved CO

8 xx8 xx

CASE STUDY

ALCOHOL SEPTAL ABLATION

9 xx9 xx

CASE STUDY

A PATIENT WITH HOCM

• 76 yo female• Admitted with increasing DOE times several

months, worsening in the previous week

• PMH• HOCM- currently taking Atenolol (Tenormin)• HTN• Severe MR• Remote tobacco• EtOH• No family history of cardiac disease

10 xx10 xx

CASE STUDY

PATIENT ASSESSMENT

• ACS ruled out• No positive cardiac enzymes

• PE unlikely• No risk factors

• Diagnosis: CHF from HOCM and MR

• Treatment Plan: Left Heart Cath with Alcohol Septal Ablation

11 xx11 xx

CASE STUDY

PRE PROCEDURE ECHO FINDINGS

Prominent LVH with hyperdynamic LV function (EF > 75%), severe LVOT gradient, severe MR

Demo images

12 xx12 xx

CASE STUDY

LEFT HEART CATH PROCEDURE

• No significant coronary disease• Initial measurement of LV gradient: 130

mmHg• Gradient after injection of 2.5 ml ethanol: 30

mmHg

Demo image

13 xx13 xx

CASE STUDY

PERI- AND POST-OP COURSE

• During procedure, patient developed RBBB• Temporary pacing wire inserted

• Patient sent to CCU• Did not need pacing overnight (VVI 40),

and temp wire removed

• Next day, patient sat up in bed and had long period of ventricular asystole, followed by ventricular escape rhythm of 20bpm

14 xx14 xx

CASE STUDY

DIAGNOSIS

• Paroxysmal AV Block

• Patient given Dopamine infusion and Atropine bolus• Return of 1:1 AV conduction

• Temp wire reinserted in right IJ, set at VVI 70bpm

15 xx15 xx

CASE STUDY

OUTCOME

• Patient received dual chamber pacemaker • STJ Zephyr• Tendril STS leads, 46cm and 52 cm• Normal sensing and capture threshold

measurements

• Temp wire removed under fluoro to ensure new leads were not dislodged

16 xx16 xx

CASE STUDY

SUMMARY

• HCM is a rare, sometimes lethal condition

• Alcohol septal ablation is an effective procedure for the treatment of symptomatic HCM

• Complications can occur with any procedure