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Interesting septal ablation case today - love to hear opinions about management. 70 ish year old with dyspnea and angina. Echo shows HCM with LVOT obstruction. Significant SAM driven MR seen.
Cath confirms severe outflow obstruction.
Angiography shows severe LAD stenosis at site of septal origin. Ostial septal severely stenotic with early bifurcation into multiple small rami.
Patient is not a candidate for CV surgery. She remains symptomatic on maximal medical therapy. What now:
After discussion with patient, we decide to pursue ablation plus stenting. Septal wiring is difficult but accomplished with a wicked bend on a Whisper wire:
Over the wire balloon advanced into septal. Patient starts to become hypotensive and has chest pain. Angiogram shown below:
Do we think this is a:
ACT checked and above 300s. I wired the LAD and dilated to 6atm with a 2.5mm balloon. Chest pain improves and pressure stabilizes. Repeat angiogram below:
At this point should we:
I decide to continue with ablation since it is impossible to wire septal after stenting. Covered stenting unlike to reduce septum if collateral recruitment occurs. Balloon in LAD left in place to scaffold vessel open. Septal balloon is inflated and shows good seal:
Contrast injection down 1.5mmx6mm OTW balloon shows no occult collateral development and confirms balloon sealing at ostium:
Optison injection shows good basal septal targeting without any collateral sites lighting up:
