Therapeutic approach to severe hypertrophic obstructive cardiomyopathy with multivessel coronary artery disease

The association of severe hypertrophic obstructive cardiomyopathy and coron ary artery disease increases surgical morbimortality, even more in patients over 65 years. We describe a combined therapeutic approach to these diseas es. A 68-year-old woman with a diagnosis of hypertrophic obstructive cardiomyop athy was in functional class IV for angina and dyspnea despite 360 mg of pr opranolol a day. An echocardiogram and a complete cardiac catheterization w ere performed under betablocker therapy, confirming a severe hypertrophic o bstructive cardiomyopathy and revealing severe stenosis in the proximal lef t circumflex and the proximal right coronary arteries, and a moderate lesio n in the mid-left anterior descendent. They mere both treated with balloon PTCA, and a 3 x 15 mm stent was placed in the circumflex and a 3.5 x 20 mm stent in the right coronary, with an excellent angiographic result. A basal hemodynamic study was then performed and A-V sequential pacing was attempt ed, achieving a significant decrease in the left ventricle outflow tract gr adient. A DDD-R pacemaker was implanted. Echocardiographic study was perfor med post-implantation, and follow-up was made six months later with a new c oronary angiography, hemodynamic study and a Doppler echocardiogram. At the present time A-V sequential pacing as a therapeutic option for hyper trophic obstructive cardiomyopathy and coronary angioplasty and stenting fo r the treatment of coronary artery disease are sufficiently established and supported to be offered as a combined therapy to patients suffering from b oth diseases, specially those with a higher surgical risk.