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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{at}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 (arrowheads).

MRI has been used to characterize myocardial perfusion after acute myocardial infarction (MI) due to coronary artery disease (CAD). An area of subendocardial hypoenhancement or perfusion defect is often seen on first-pass imaging, and this usually corresponds to microvascular obstruction. On delayed imaging, this subendocardial region becomes hyperenhanced along with the surrounding infarcted territory. NSSR with ethanol creates a localized infarct. Ethanol causes significant microvascular obstruction such that contrast penetration is extremely slow. Hence, the delayed image obtained shortly after the procedure shows patchy hyperenhancement. With time, the extent of microvascular obstruction declines, as seen after acute MI due to CAD. Thus, the images taken 3 weeks after the procedure show a less severe first-pass perfusion defect and greater hyperenhancement on delayed imaging. In the setting of acute MI due to CAD, microvascular obstruction affects left ventricular remodeling. How this influences the long-term outcome of hypertrophic obstructive cardiomyopathy patients who have had NSSR remains unknown.

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wu, K. C. Articles by Lima, J. A.C. Search for Related Content PubMed PubMed Citation Articles by Wu, K. C. Articles by Lima, J. A.C. Related Collections Cardiovascular imaging agents/Techniques CT and MRI