Author + information
- Received May 7, 2018
- Accepted May 15, 2018
- Published online September 12, 2018.
- aKlinikum Wuerzburg Mitte–Standort Juliusspital, Würzburg, Germany
- bLeopoldina-Krankenhaus Schweinfurt, Schweinfurt, Germany
- ↵∗Address for correspondence:
Prof. Hubert Seggewiss, Klinikum Würzburg Mitte–Standort Juliuspital, Juliuspromenade 19, 97070 Würzburg, Germany.
Percutaneous alcohol septal ablation (PTSMA) has been established as therapy in symptomatic patients with hypertrophic obstructive cardiomyopathy (1). Collateralization between the target septal branch and the left anterior descending coronary artery as well as another septal branch with potential risk for myocardial infarction has been described (2,3). We report on a patient with collateral vessels between the target septal branch and the right coronary artery and successful interventional treatment of this previously undescribed finding.
A 66-year-old woman was first seen in November 2016 with highly symptomatic hypertrophic obstructive cardiomyopathy. Echocardiography showed long subaortic and midcavitary obstruction with high gradients at rest (55 mm Hg) and with Valsalva maneuver (100 mm Hg). Because of reduced but still significant midcavitary gradient after first PTSMA with circumscribed subaortic scar, repeat PTSMA was performed 6 months later. After placement of a 1.5/6-mm over-the-wire balloon (Sprinter, Medtronic, Minneapolis, Minnesota) in the septal branch (Figure 1), contrast echocardiography with injection of 1.5 ml agitated cooled Gelafundin 4% showed optimal opacification of the septum and additional unwanted opacification of the apicolateral wall (Figure 2). We injected 1 ml radiographic contrast dye through the central lumen of the over-the-wire balloon and detected collateral flow from the target septal branch to the distal right descendens posterior of the right coronary artery. The connection between the right coronary artery and target septal branch was identified by simultaneous angiography of the left and right coronary arteries. The collateralized side branch of the right descendens posterior was wired with a BMW wire, and a 1.5/6-mm monorail percutaneous coronary intervention balloon (Solaris) was placed and inflated to 6 atm. Two milliliters of alcohol was slowly injected after repeated myocardial contrast echo and contrast dye injection through the over-the-wire PTSMA balloon had shown no misplacement and collateralization between the target septal branch and any other vessel. Gradients were eliminated. Maximal creatine kinase increase was 650 U/l. No complication was observed during hospital stay and 9-month follow-up.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 7, 2018.
- Accepted May 15, 2018.
- 2018 The Authors
- Nishimura R.A.,
- Seggewiss H.,
- Schaff H.V.
- Parham W.A.,
- Kern M.J.