Ann Thorac Surg 2002;73:649-650
© 2002 The Society of Thoracic Surgeons
Case report
Recurrence of left ventricular outflow tract obstruction after left anterior descending coronary artery revascularization in a patient with hypertrophic obstructive cardiomyopathy
Simon J. Abou Jaoudé, MDa,
Paul E. Achouh, MDb,
Ramzi A. Ashoush, MDb,
Victor A. Jebara, MD*b
a Department of Cardiology, Hôtel Dieu de France, Beirut, Lebanon
b Department of Cardiovascular Surgery, Hôtel Dieu de France, Beirut, Lebanon
Accepted for publication April 17, 2001.
* Address reprint requests to Dr Jebara, Department of Cardiovascular and Thoracic Surgery, Hôtel Dieu de France, Rue Adib Ishac, Beirut, Lebanon
e-mail: vix{at}dm.net.lb
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Abstract
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A patient with known hypertrophic obstructive cardiomyopathy presented with an anteroseptal myocardial infarction which resulted in the disappearance of his subaortic pressure gradient. Surgical revascularization of his left anterior descending coronary artery after the viability of his myocardium had been documented led to the recurrence of his left ventricular outflow tract obstruction and subaortic pressure gradient.
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Introduction
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Controversy remains as to the optimal treatment of patients with hypertrophic obstructive cardiomyopathy (HOCM), who remain severely symptomatic despite optimal medical therapy. Until recently, surgery was the only treatment available for these patients. The past decade has witnessed the emergence of two less invasive therapeutic modalities: dual-chamber pacemaker implantation [1, 2] and septal reduction therapy with ethanol [1–5]. Percutaneous transluminal septal myocardial ablation [1] aims at decreasing outflow obstruction by creating septal infarction and fibrosis. In spite of several encouraging reports on the successful use of this technique in a relatively important number of patients, some reluctance continues as to the benefits of this procedure for patients with HOCM.
We report the case of a patient with known HOCM who suffered from an anteroseptal myocardial infarction with subsequent cure of the left ventricular outflow tract (LVOT) obstruction and disappearance of the subaortic pressure gradient. Surgical revascularization of the left anterior descending coronary artery (LAD) resulted in improvement of ventricular contractility and recurrence of the LVOT obstruction.
A 56-year-old man was admitted for a recent episode of palpitation and dyspnea. Electrocardiogram showed rapid atrial fibrillation and signs consistent with a nonacute anteroseptal myocardial infarction. Cardiac enzymes (creatine phosphoskinase) were normal; however, qualitative troponin-T test was positive. He was being followed at our department for a history of HOCM diagnosed at the age of 45 and was receiving beta blockers since the age of 58. Serial echocardiographic studies, during the past 5 years, showed LVOT obstruction due to a prominent septal hypertrophy and a subaortic gradient oscillating between 40 and 60 mm Hg. The patient was totally asymptomatic. A recent electrocardiogram obtained 3 months prior to his present admission showed normal sinus rhythm with no signs of myocardial infarction.
Transthoracic echocardiography performed at admission showed severe hypokinesis of both the anteroapical wall and the septum consistent with a myocardial infarction. Interestingly, no subaortic gradient could be noted. Amiodarone was administered and anticoagulation was started. A coronary angiogram showed total occlusion of the LAD at its origin from the left main coronary artery with minimal retrograde filling from the right coronary system. The rest of the coronary arteries were free of disease. Left ventricular angiography showed akinesis of the anteroapical wall as well as akinesis of the septum. Pressure monitoring in the ventricular cavity could not demonstrate any gradient. There was no mitral regurgitation.
In order to assess the viability of the akinetic ventricular wall, a Thallium scan was obtained and revealed a limited infarction with a large area of residual ischemia in favor of viable muscle. Since angioplasty was considered hazardous due to the proximal site of the obstruction, surgical procedure was performed constructing a left internal mammary artery to the LAD. The postoperative course was uneventful. However, on day 4 and prior to discharge, a loud systolic murmur was noted which was not present either at admission or during the first 3 postoperative days. Transthoracic echocardiography showed a significant improvement of left ventricular contractility including the anterior wall and the septum with recurrence of the LVOT obstruction and a gradient of 65 mm Hg. The patient was totally asymptomatic and was discharged under calcium channel blockers (diltiazem) as is our routine policy for patients receiving arterial grafts.
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Comment
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We report of abolition of LVOT obstruction secondary to anteroseptal infarction with recurrence of the gradient following surgical revascularization. Moreover, this case constitutes additional evidence for the efficacy of percutaneous transluminal septal myocardial ablation in patients with HOCM. Finally, this observation raises the question of whether myomectomy should be performed concomitantly with surgical revascularization.
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References
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Fananapazir L., McAreavey D. Therapeutic options in patients with obstructive hypertrophic cardiomyopathy and severe drug-refractory symptoms. J Am Coll Cardiol 1998;31:259-264.[Free Full Text]
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Nishimura R.A., Trusty J.M., Hayes D.L., et al. Dual-chamber pacing for hypertrophic cardiomyopathy. A randomized, double-blind, crossover trial. J Am Coll Cardiol 1997;29:435-441.[Abstract]
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Lakkis N.M., Nagueh S.F., Dunn J.K., Killip D., Spencer W.H. Nonsurgical septal reduction therapy for hypertrophic obstructive cardiomyopathy: one-year follow up. J Am Coll Cardiol 2000;36:852-855.[Abstract/Free Full Text]
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Sigwart U. Non-surgical myocardial reduction for hypertrophic obstructive cardiomyopathy. Lancet 1995;346:211-214.[Medline]
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Seggewiss H., Gleichmann U., Faber L., Fassbender D., Schmidt H.K., Strick S. Percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy. J Am Coll Cardiol 1998;31:252-258.[Abstract/Free Full Text]
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Abstract
Introduction
