Partial epicardial coronary artery occlusion during percutaneous transcoronary septal myocardial ablation (PTSMA)
█ Case report
Szűcsborus Tamás1, Pálinkás Attila2, Takács Hedvig1, Pálinkás Eszter1, Ungi Imre1
1Szegedi Tudományegyetem, II. sz. Belgyógyászati Klinika és Kardiológiai Központ, Szeged
2Erzsébet Kórház, Belgyógyászati Osztály, Hódmezővásárhely
Background: Percutaneous transcoronary septal myocardium ablation (PTSMA) is a catheter-based method to relieve the left ventricular outflow tract (LVOT) obstruction in hypertrophic cardiomyopathy (HCM).
Case history: A female patient, aged 42 years at the time of assessment, has been diagnosed with obstructive hypertrophic cardiomyopathy (HCM) 8 years earlier. Echocardiography revealed a resting left ventricular outflow tract (LVOT) peak gradient of 50 mmHg, which rose to 70 mmHg on provocation and to 125 mmHg on exercise, associated frequently with near-syncope. Because of the NYHA III functional status and the repeated syncopal attacks, persisting despite of optimal pharmacologic therapy, PTSMA was performed. During PTSMA selective and sub-selective angiography and contrast echocardiography was performed which did not reveal evident abnormal collateral connections. However, the alcohol, injected during ablation, may have propagated to the distal part of the right coronary artery, through functional abnormal collaterals, causing unwanted partial vessel closure and myocardial necrosis. Short and mid-term follow up indicated that hemodynamic results of PTSMA was excellent with no relevant clinical outcomes regarding the distal right coronary partial occlusion.
Conclusion: PTSMA is a safe and effective treatment modality for gradient reduction in patients with obstructive HCM selected on appropriate criteria for the procedure. The rigorous assessment of potential abnormal collateral connections between coronary branches are mandatory and frequently requires the modification of the original treatment plan. However, non-visible, functional collaterals might be present which may cause unwanted myocardial necrosis in remote myocardial areas, as was demonstrated in our case.