Guiding of percutaneous transcoronary septal myocardial ablation in hypertrophic obstructive cardiomyopathy by myocardial contrast echocardiography

Percutaneous transluminal septal myocardial ablation (PTSMA) by alcohol injection into septal branches (SB) of the left coronary artery has evolved as a promising therapeutic option for selected patients with obstructive hypertrophic cardiomyopathy (HOCM). Originally, probatory balloon occlusion of the target vessel was considered to be predictive for definitive reduction of left ventricular outflow gradients (LVOTG). The need for additional information regarding the exact site and extension of the therapeutic septal infarction is demonstrated by a case report. In this patient, myocardial contrast echocardiography (MCE) was performed prior to alcohol injection and showed that the septal area corresponding to LVOTG formation was supplied by a SE originating atypically from an intermediate branch. PTSMA guided by MCE led to complete LVOTG elimination without sustained rhythm disturbances and with a minimum CK rise.