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Recent meta-analyses have shown good long-term survivalof patients with hypertrophic obstructive cardiomyopathy(HOCM) after alcohol septal ablation (ASA) comparablewith surgical myectomy. However, gradient reduction afterASA was slightly less favourable [1, 2] and in a single-centre study a higher rate of aborted sudden cardiac deathwas found [3]. The following case report illustrates theimportance of coronary anatomy and infarction location indetermining the outcome after ASA.Case reportA 53-year-old male patient was referred to undergoalcohol septal ablation (ASA) for symptoms due tohypertrophic obstructive cardiomyopathy despite medicaltherapy. His echocardiogram revealed a septal wallthickness of 18 mm, severe systolic anterior motion ofthe mitral valve and a severe posterolaterally directed mitralvalve regurgitation. The gradient in the left ventricularoutflow tract was 54 mmHg at rest and 100 mmHg aftervalsalva manoeuvres.Coronary angiography revealed two septal branches ofwhich the first was very small and could not becannulated. Subsequently, the second branch (S2) wascannulated (Fig. 1) and myocardial contrast echocardiog-raphy(MCE)wasusedtodelineatetheperfusedareaacross the septal contact areaof the mitral valve. However,during probatory inflation of the balloon the invasivelymeasured gradient was only reduced from 60 mmHg to50 mmHg (Fig. 2a and 2b). Also after injection of 2 ml ofalcohol, the gradient remained elevated at 50 mmHg.Therefore, after perseverance, the smaller and moreproximal septal branch was successfully cannulated. Afterprobatory inflation of the balloon, the gradient resolvedcompletely and this septal branch was ablated as well(Fig. 2c). The second ablation resulted in completeresolution of the outflow tract gradient (Fig.2d), but wasoffset by the necessity for pacemaker implantation due tototal AV block. An MRI was performed three days afterthe procedure and revealed an infarction of the entire basalpart of the septum (Fig.3). At three months follow-up theechocardiogram revealed a gradient in the outflow tract ofonly 10 mmHg and the patient no longer experiencedshortness of breath.DiscussionPatients with HOCM can exhibit severely reducedexercise tolerance. A prevalvular obstruction is causedby a thickened protruding septum and systolic anteriormotion of the mitral valve (SAM). Gradient reductioncan be achieved by surgical removal of part of thethickened septum or by ASA. With ASA, alcohol isselectively infused in an appropriate septal branch. Thiscauses infarction and thinning of the septum. Firstprobatory balloon inflation and later myocardial contrastechocardiography (MCE) were introduced for guidanceand selection of the appropriate branch for ASA.

Optimal gradient reduction after alcohol septal ablation: a case report with anatomical and practical determinants