Author + information
- Received October 13, 2016
- Accepted October 20, 2016
- Published online January 16, 2017.
- Takashi Yanagiuchi, MD∗ (, )
- Norio Tada, MD,
- Yukiko Mizutani, MD,
- Takashi Matsumoto, MD,
- Mie Sakurai, MD and
- Tatsushi Ootomo, MD
- ↵∗Reprint requests and correspondence:
Dr. Takashi Yanagiuchi, Sendai Kousei Hospital, Cardiology, Hirosemachi, Aoba-ku, Sendai, Miyagi 980-0873, Japan.
- alcohol septal ablation
- left ventricular outflow tract obstruction
- multidetector computed tomography
- transcatheter aortic valve replacement
An 83-year-old man was referred for transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Preoperative 320–detector row multidetector computed tomography revealed aortic valve calcification and an asymmetrically thickened basal interventricular septum. Reconstruction of a volumetric dataset every 10% of the cardiac cycle using ZIOSTATION 2 (Ziosoft, Tokyo, Japan) revealed systolic anterior motion of the mitral valve with elongated chordae (Figure 1A). A 3-dimensional volume-rendered image of the coronary arteries and a 2-dimensional image of the myocardium in diastole were fused into a single image (Figure 1B) to assess the spatial relationship between the septal branches and myocardium (1). The second septal branch perfused the entire hypertrophic myocardium at the basal interventricular septum, which contacted the anterior mitral leaflet in systole and was an optimal target for alcohol septal ablation (ASA). Thus, we planned TAVR considering ASA as a rescue option. After a 26-mm SAPIEN 3 valve (Edwards Lifesciences, Irvine, California) was implanted via the femoral artery, the patient’s blood pressure decreased, and a left ventricular outflow tract (LVOT) obstruction was detected with a 121 mm Hg peak pressure gradient by transesophageal echocardiography (Figure 1C). Ad hoc ASA was subsequently performed (Figures 1D to 1F), and the LVOT pressure gradient was normalized after second septal branch ablation. One-month follow-up echocardiography revealed thinning of the basal interventricular septum without a significant LVOT gradient.
Asymmetrical septal left ventricular hypertrophy is sometimes associated with aortic stenosis, which might lead to acute deterioration because of dynamic LVOT gradients after valvular afterload removal (2,3). Cardiovascular medication does not always improve hemodynamic status. Because septal myectomy is not an option in the clinical setting of TAVR, ASA might be the only solution. However, approximately 20% patients do not have septal arteries suitable for ablation (4). Therefore, it is crucial to assess ASA’s anatomic feasibility with multidetector computed tomography when deciding the indication of TAVR.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 13, 2016.
- Accepted October 20, 2016.
- American College of Cardiology Foundation