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(Circulation. 2001;104:1868.)
© 2001 American Heart Association, Inc.

Images in Cardiovascular Medicine

Microvascular Obstruction After Nonsurgical Septal Reduction for the Treatment of Hypertrophic Cardiomyopathy

Katherine C. Wu, MD; Alan W. Heldman, MD; Jeffrey A. Brinker, MD; Joshua M. Hare, MD; João A.C. Lima, MD

From the Department of Medicine and Division of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Md.

Correspondence to Dr Katherine C. Wu, The Johns Hopkins Hospital, Division of Cardiology, Carnegie 568, 600 North Wolfe Street, Baltimore, MD 21287-6568. E-mail kwu@jhmi.edu

A 47-year-old woman with hypertrophic obstructive cardiomyopathy presented with worsening exertional dyspnea, paroxysmal nocturnal dyspnea, and chest pain, despite maximal medical therapy. Echocardiography showed severe ventricular hypertrophy, left ventricular outflow tract (LVOT) narrowing, a 110 mm Hg LVOT gradient, and systolic anterior motion of the mitral valve. She was referred for nonsurgical septal reduction (NSSR). Coronary angiography revealed 3 proximal septal branches of the left anterior descending artery; each was injected with ethanol through an occlusive balloon catheter. Final angiography showed low flow and incomplete contrast penetration into the treated septal branches. The patient’s LVOT gradient declined to 65 mm Hg, and she improved symptomatically. Contrast-enhanced MRI was performed at 3 time points ().

View larger version (103K): [in this window] [in a new window]   Contrast-enhanced MRI using fast gradient echo sequences was performed before the procedure and at 2 days and 3 weeks after the procedure. First-pass images were acquired within 20 seconds of contrast injection, while delayed images were acquired 30 minutes after contrast bolus. Baseline short (A) and long-axis (B) images show homogeneous myocardial signal intensity in the base to the midventricle. Two days after septal reduction, the first-pass short-axis image (C) shows a transmural perfusion defect (ie, lack of contrast uptake or hypoenhancement) in the proximal septal region (arrowheads). The delayed, long-axis image (D) shows continued poor contrast penetration into the septal region, with patchy hyperenhancement (arrowheads). Three weeks after treatment, the first-pass image (E) shows a smaller septal perfusion defect (arrowheads). The corresponding delayed long-axis image (F) shows greater contrast penetration than at day 2 . . . [Full Text of this Article]

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