ECHOCARDIOGRAPHY-GUIDED ETHANOL SEPTAL REDUCTION FOR HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY

Background-Left ventricular outflow tract (LVOT) obstruction is freque ntly responsible for symptoms in hypertrophic obstructive cardiomyopat hy (HOCM). Medical therapy is often not sufficient to control these sy mptoms, and surgical myotomy-myomectomy is required. Methods and Resul ts-We enrolled 33 symptomatic patients with HOCM and obstruction (grea ter than or equal to 40 mm Hg gradient at rest or greater than or equa l to 60 mm Hg dobutamine-provoked). By contrast echocardiography, the bulging septum was localized and infarcted by injection of 2 to 5 mL o f absolute ethanol into the septal artery(ies) supplying the hypertrop hied area. Baseline echocardiograms with Doppler, myocardial perfusion tomograms, and treadmill exercise or pharmacological testing were com pared with those at 6 weeks and 6 months. The mean rise in creatine ki nase was 1964+/-796 U. All patients experienced symptomatic relief; NY HA class decreased from 3.0+/-0.5 to 0.9+/-0.6 (P<0.001). Exercise tim e increased from 286+/-193 to 421+/-181 seconds (P=0.03). The resting and dobutamine-provoked gradient decreased from 49+/-33 and 96+/-34 mm Hg to 9+/-19 (P<0.001) and 24+/-31 mm Hg (P<0.001), respectively. Ech ocardiograms repeated at 6 weeks after the procedure showed a 28% redu ction in septal thickness and 17% reduction in left ventricular mass. Myocardial perfusion imaging showed a ''septal amputation pattern,'' w ith scarring in the upper and middle septal areas. Complete heart bloc k developed in 11 patients, who then required permanent pacemaker impl antation. Conclusions-Echocardiography-guided ethanol septal reduction in patients with HOCM is a safe, minimally invasive procedure that pr ovides symptomatic relief with improved hemodynamic and left ventricul ar parameters.