Author + information
- Received January 21, 2016
- Accepted February 11, 2016
- Published online June 13, 2016.
- Metin Çağdaş, PhDa,∗ (, )
- Süleyman Karakoyun, PhDa,
- Mahmut Yesin, MDb,
- İbrahim Rencüzoğulları, PhDa,
- İnanç Artaç, MDa and
- Tufan Çınar, MDc
- aCardiology Department, Kafkas University Training and Research Hospital, Kars, Turkey
- bCardiology Department, Kars Harakani State Hospital, Kars, Turkey
- cCardiology Department, Lüleburgaz State Hospital, Kirklareli, Turkey
- ↵∗Reprint requests and correspondence:
Dr. Metin Çağdaş, Cardiology Department, Kafkas University Training and Research Hospital, Turan Çelik Street, 20037 Kars, Turkey.
A 52-year-old female patient presented to cardiology clinic with symptoms of exertion dyspnea, orthopnea, and swelling of both legs that had progressed in past 3 months. On physical examination, her blood pressure was 117/85 mm Hg, and her pulse was 72 beats/min. Cardiac auscultation revealed a 3/6 systolic murmur over the apex and along the left parasternal border. The electrocardiogram showed normal sinus rhythm and left ventricular hypertrophy. Echocardiography demonstrated an interventricular septum (IVS) thickness was 19 mm on echocardiographic evaluation systolic anterior motion of the anterior mitral valve leaflet (SAM) (Figure 1A), mild mitral regurgitation, and a resting left ventricular outflow tract (LVOT) gradient of 81 mm Hg (Figure 1B). Low-dose intravenous furosemide was added to metoprolol treatment. Pre-tibial edema and orthopnea decreased on follow-up the next day. Because the patient refused surgery, she was scheduled for septal embolization. Coronary angiography performed via the right femoral artery showed atherosclerotic coronary artery disease without significant stenosis. The dominant septal artery was determined from the right anterior oblique cranial angle view (Figure 1C). The septal artery was passed through with a soft guidewire. An over-the-wire (OTW) balloon 1.5 × 8 mm in diameter was placed proximal to the dominant septal artery via the guidewire. The balloon was inflated to 10 atm until antegrade flow stopped. The basal-septal and mitral-septal contact locations were confirmed by administering agitated saline solution (10% air, 90% saline mixture) through the OTW balloon (Figure 1D). A microcatheter was placed proximal to the septal artery. Subcutaneous fat tissue was removed from the inguinal area and cut into 1 × 1-mm sections (Figure 1E). A total of 5 pieces of subcutaneous fat tissue were injected into the septal artery via the microcathater one by one. After withdrawal of the microcatheter, coronary angiography was performed, and the septal artery was found to be totally occluded (Figure 1F). Echocardiography showed decreasing SAM, a resting LVOT gradient of 23 mm Hg that increased to 42 mm Hg after the Valsalva maneuver (Figure 1G). The patient was discharged on day 5 after the procedure. At 3-month follow-up, the patient was asymptomatic; echocardiography showed no SAM and a resting LVOT gradient of 14 mm Hg that increased to 28 mm Hg after the Valsalva maneuver (Figures 1H and 1I).
Occlusion of the septal artery might have more predictable results compared with alcohol septal ablation and with several techniques (coiling , cyanoacrylate mixture , microsphere embolization ) described in published reports. Subcutaneous fat embolization is an effective and inexpensive method for the treatment of distal coronary perforation that develops during percutaneous coronary intervention (4), and we considered that this technique could be used in hypertrophic obstructive cardiomyopathy patients who refuse the surgical myectomy. After the procedure, we observed a significant reduction in the periprocedural LVOT gradient and improvement in symptoms and echocardiographic findings during follow-up visits and did not encounter any complications. We conclude that subcutaneous fat embolization could be practical and low-cost alternative to other septal occlusion techniques.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 21, 2016.
- Accepted February 11, 2016.
- American College of Cardiology Foundation