Interventional treatment of hypertrophic obstructive cardiomyopathy has considerably developed and primary surgical approach is nowadays considered for a minority of patients with insufficient relief of obstruction following catheter intervention. We present the history of a patient who underwent alcohol ablation and developed a life-threatening ventricular septal defect consecutively to a large myocardial infarction because of alcohol injection into the LA

Carrel, Thierry

Schmidli, Jürg

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Case reportSeptal myectomy for hypertrophic obstructive cardiomyopathy:coil, boil and the role of rescue surgeryThierry Carrel *, Ju¨rg SchmidliDepartment of Cardiovascular Surgery, University Hospital Berne, CH-3010 Berne, SwitzerlandReceived 28 October 2008; received in revised form 16 March 2009; accepted 17 March 2009; Available online 1 May 2009AbstractInterventional treatment of hypertrophic obstructive cardiomyopathy has considerably developed and primary surgical approach is nowadaysconsidered for a minority of patients with insufficient relief of obstruction following catheter intervention. We present the history of a patientwho underwent alcohol ablation and developed a life-threatening ventricular septal defect consecutively to a large myocardial infarctionbecause of alcohol injection into the LAD.# 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.Keywords: Hypertrophic cardiomyopathy; Coil embolisation; Alcohol ablation; Surgery; Complicationswww.elsevier.com/locate/ejctsEuropean Journal of Cardio-thoracic Surgery 36 (2009) 210—2111. IntroductionTreatment of hypertrophic obstructive cardiomyopathy(HOCM) was exclusively a surgical topic until new transcath-eter intervention methods were demonstrated to besuccessful as well. Recently, Durand and co-authorsdescribed the feasibility of coil embolisation for thetreatment of HOCM. Twenty patients with drug-refractorysymptoms underwent septal reduction using embolisation ofdetachable coils [1]. Occlusion of septal branches was‘successfully’ performed in all patients. No patient devel-oped heart block or ventricular tachycardia. However, onepatient developed post-interventional ventricular septaldefect (VSD) and died 19 days following the procedure. At6-month follow-up, functional class and peak oxygenconsumption significantly improved compared to baseline.Echocardiography showed a significant ( p < 0.001) reductionof the septum thickness (21  3 to 17  4 mm) and LVOTpressure gradient (80  29 to 35  29 mmHg).In the same journal, Togni and co-authors emphasised thesuccessful results [2]. As usual for the evaluation of aninterventional procedure, the follow-up was very short. Inthis context, one should not forget that surgical myectomyhas been shown to provide excellent durable results, withsurvival rates similar to those of a normal population [3].The post-infarction VSD, a life-threatening complication,is described with a few words only [1]. Unfortunately, papersdealing with the transcatheter options for HOCM do not* Corresponding author. Tel.: +41 31 632 23 75; fax: +41 31 632 44 43.E-mail address: thierry.carrel@insel.ch (T. Carrel).1010-7940/$ — see front matter # 2009 European Association for Cardio-Thoracic Sdoi:10.1016/j.ejcts.2009.03.033address this disastrous complication for the simple reasonthat once it has occurred, it turns out to be a surgicalproblem. Interestingly, the most comprehensive paper onthat issue has not been published by cardiologists but bypathologists [4]!In a recent comment on alcohol ablation, Sigwart claimedthat alcohol ablation can be guided very precisely by 2D-echocardiography [5]. The following observation emphasisesthe fact that this affirmation remains speculative, even in thehands of very experienced interventional cardiologists.2. Case reportA 60-year-old female patient was referred because ofshortness of breath functional class NYHA II, dizziness anduncharacteristic thoracic pains. Echocardiography showed aclassical HOCM with systolic anterior motion of the mitralvalve and consecutive mild mitral regurgitation. LVOT mean/maximal pressure gradients were 102/207 mmHg at rest and150/250 mmHg following amylnitrit testing. There was asignificant LV-hypertrophy but systolic function was normal(EF 65%). Treatment consisted of nifedipin 2  80 mg dailyand magnesium.Indication for alcohol ablation was confirmed. Duringcoronary angiography, 2.5 ml of alcohol 95% were injectedduring11 min in the 1st septal branch. Somealcohol camebackin the LADwhich resulted in immediate LAD occlusion. ATITAN-stent was implanted but there was a no-reflow phenomenon.Mean, resp. maximal pressure gradient was described to havedecreased from 68/112 to 12 mmHg immediately after theprocedure. One day following the procedure, the mean/maxurgery. Published by Elsevier B.V. All rights reserved.T. Carrel, J. Schmidli / European Journal of Cardio-thoracic Surgery 36 (2009) 210—211 211Fig. 1. TEE with four chamber view showing the large VSD at the mid-ventricular septum.pressure gradient at rest was still significant 48/95 mmHg,despite the fact that the LV-function had considerablydeteriorated (EF 45%) due to a large antero-septal myocardialinfarction (maximal CK 4000 micromol/ml). Post-interven-tional bleeding at the femoral artery punction site requiredtransfusion of 2 packs of erythrocytes. On post-procedural day2, the patient complained about retrosternal pains anddeveloped haemodynamic instability. Echocardiographyshowed a non-restrictive ventricular septal defect, a mild tomoderate mitral regurgitation and a circular pericardialeffusion (Fig. 1).Becauseof increasinghaemodynamic instability, immediatesurgery was performed under moderate hypothermic cardio-pulmonary bypass. The VSD was approached through a leftventriculotomyparallel totheLADandclosedwithapericardialpatch using interrupted sutures. The hypertrophic septumwasresected from below the aortic valve until deep into the leftventricle and the papillarymuscles weremobilised. Themitralvalve was repaired with an annuloplasty ring.Unfortunately, the LAD could not be revascularised since itwas completely thrombosed. Weaning from cardiopulmonarybypass required substantial inotropic support. Pacemakerwas necessary because of av block III. Recovery wasprolonged. Postoperative echocardiography on the ICU andbefore discharge (on p.o. day 25) showed trivial residual VSD,no residual gradient across the LVOT, a trivial mitralregurgitation. LV-EF was 45%.3. CommentThis case illustrates that surgical myectomy for HOCMtreatment is considered less and less frequently due toincreasing enthusiasm for catheter-based interventions.During decades, the gold standard for treatment of HOCMhas been surgical resection with excellent short- and long-term results [3,6]. In the last 15 years, alcohol ablation andmost recently coil embolisation were found to be attractiveoptions to release the LVOT pressure gradient. Increasingexperience showed that alcohol ablation penetrates moredeeply into the septal region and induces a correspondingarea of necrosis, whereas coil embolisation leads primarily toischaemia and only secondarily to necrosis.The short comment by Togni and co-authors entitled‘Septal myectomy: cut, coil or boil?’ does unfortunately notaddress the advantages of the surgical approach which allowsthe most precise and complete resection under view and themobilisation of the papillary muscles from the hypertrophiedseptum and the free left-ventricular wall. In addition, it doesnot address the problem of iatrogenic VSD and its obligatorytreatment [7].Working closely with the cardiologists (which has beendone extremely successfully during the last 10 years in ourinstitution) may attenuate the fact that surgery is consideredonly to rescue patients from life-threatening complicationsfollowing catheter interventions. However, it will benecessary to re-assess some of the very long-term resultsof standard surgical procedures to ensure objective compar-ison with the new, less invasive techniques.In the case described above, the surgical approachallowed precise and complete resection of the hypertrophicseptum and was able to abolish (and not only to reduce) theLVOT pressure gradient, which was still significant followingalcohol ablation. In addition, surgery allowed for additionalrepair of the mitral valve but due to complete occlusion ofthe LAD, no revascularisation was performed. Since alcoholinduces a chemical lesion, the reason for stent insertion(additional foreign material) was not clear: it might havebeen a typical cardiologist’s ‘reflex’ to treat acute coronaryocclusion.We conclude that surgical treatment has still a role to playin HOCM disease and should not be limited to the treatmentof life-threatening complications [8,9].References[1] Durand E, Mousseaux E, Coste P, Pillie`re R, Dubourg O, Trinquart L,Chatellier G, Hage`ge A, Desnos M, Lafont A. Non-surgical septal myocardialreduction by coil embolization for hypertrophic obstructive cardiomyo-pathy: early and 6 months follow-up. Eur Heart J 2008;29:348—55.[2] Togni M, Billinger M, Cook S, Hess O. Septal myectomy: cut, coil or boil? EurHeart J 2008;29:296—8.[3] Schoendube FA, Klues HG, Reith S, Flachskampf FA, Hanrath P, Messmer BJ.Long-term clinical and echocardiographic follow-up after surgical correc-tion of hypertrophic obstructive cardiomyopathy with extendedmyectomyand reconstruction of the subvalvular mitral apparatus. Circulation1995;92(Suppl. II):II122—7.[4] Batalis NI, Harley RA, Collins KA. Iatrogenic deaths following treatment forhypertrophic obstructive cardiomyopathy: case reports and approach tothe autopsy and death certification. Am J Forensic Med Pathol 2005;26:343—8.[5] Sigwart U. Non surgical myocardial reduction for hypertrophic obstructivecardiomyopathy. Lancet 1995;346:211—4.[6] Schulte HD, Bircks W, Lo¨sse B. Techniques and complications of transaorticsubvalvular myectomy in patients with hypertrophic obstructive cardio-myopathy. Z Kardiol 1987;76(Suppl. 3):145—51.[7] Aroney CN, Goh TH, Hourigan LA, Dyer W. Ventricular septal rupturefollowing nonsurgical septal reduction for hypertrophic cardiomyopathy:treatmentwith percutaneous closure. Catheter Cardiovasc Interv 2004;61:411—4.[8] Maron BJ, McKenna WJ, Danielson GK, Kappenberger LJ, Kuhn HJ, Seid-man CE, Shah PM, SpenderWH, Spirito P, Ten Cate FJ,Wigle ED. Task Forceon Clinical Expert Consensus Documents. American College of Cardiol-ogy/European Society of Cardiology clinical expert consensus documenton hypertrophic cardiomyopathy. J Am Coll Cardiol 2003;42:1687—713.[9] Talreja DR, Nishimura RA, Edwards WD, Valeti US, Ommen SR, Tajik AJ,Dearani JA, Schaff HV, Holmes DR. Alcohol septal ablation versus surgicalseptal myomectomy: comparison of effects on atrioventricular conductiontissue. J Am Coll Cardiol 2004;44:2329—32.

Septal myectomy for hypertrophic obstructive cardiomyopathy: coil, boil and the role of rescue surgery

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