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This report describes the case of a 64-year-old woman with a previous diagnosis of obstructive hypertrophic cardiomyopathy who underwent surgical myectomy but who had a persistent midventricular residual gradient. The patient was symptomatic despite medical treatment and chose to undergo percutaneous radiofrequency (RF) ablation focused on the gradient. RF delivery was performed, and the gradient was reduced from the initial 105/68 mm Hg (during Valsalva maneuver/at rest before ablation) to 24/10 mm Hg. This reduction was sustained for the next 12 months. Percutaneous RF ablation may be a reasonable option for second surgical myectomy, and the protocol can be easily reproduced.

Background Hypertrophic obstructive cardiomyopathy (HOCM) is one of the most common genetic cardiac diseases and encompasses an array of clinical presentations. Little is known about the impact of genetic background on outcomes after septal myectomy (SM). The aim of this study was to evaluate the effect of specific genetic mutations on midterm outcomes in adults undergoing SM for HOCM. Methods From 2003 to 2020, a total of 59 patients (male = 66%, mean age = 52 ± 13) underwent SM after a preoperative genetic test. Patients were divided into two groups according to their test result (positive or negative). Preoperative echocardiograms were examined to identify phenotypical characteristics of each mutation. Results A total of thirty-one patients (53%) had a positive genetic test. MYBPC3 was the most common mutation (15/31 patients). Four different phenotypes were identified on preoperative echocardiograms. Overall, Type 1 phenotype was the most common (37% of the cohort). Type 3 was found exclusively in patients with a positive genetic test. Following SM, none of the patients required a redo myectomy or septal ablation. At 10 years, the survival was 97 ± 3% and 100% in patients with a positive and negative genetic test (p = .33), respectively. Conclusion Although our results suggest that the multiple gene mutations present with different characteristics and phenotypes, midterm results of SM appear to be good regardless of genetic mutation presence.

Objectives The aim of this study is to evaluate the impact of percutaneous transluminal septal myocardial ablation (PTSMA) on remodeling in asymptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) and severe left ventricular outflow tract (LVOT) obstruction. Background Symptoms justify invasive treatment in HOCM patients with LVOT obstruction. Adverse structural and functional changes (remodeling) in the heart occur preceding heart failure and sudden cardiac death. Early invasive treatment in asymptomatic patients may reverse adverse remodeling to the same extent as in symptomatic patients. Methods Reverse remodeling after PTSMA in severe but asymptomatic LVOT obstruction (RASTA) study is a prospective single-blind randomized trial (ClinicalTrials.gov number: NCT04230551). Ten asymptomatic HOCM patients with an exertional LVOT gradient ≥50 mmHg (or >30 mmHg in rest) are randomized 1:1 to PTSMA versus conservative therapy, in the absence of mitral valve disease or other indications for cardiac surgery. Five symptomatic (reference group) will undergo PTSMA according to the current guidelines. Results Remodeling is assessed using extensive cardiac imaging with transthoracic echocardiography and late gadolinium enhancement cardiac magnetic resonance at baseline and during follow-up at 1, 12, and 24 months. Extracellular volume fraction, global, and regional strain analysis, geometry, pressure gradients and changes in four-dimensional velocity mapping are primary parameters to study (reversal of) adverse remodeling. Conclusions The RASTA study gives insight in cardiac remodeling that may occur in asymptomatic patients after PTSMA. It will provide arguments whether to pursue (or not) a larger trial with clinical endpoints in asymptomatic HOCM patients with severe LVOT obstruction.

A 74-year-old woman with prior transcatheter aortic valve replacement using a 23-mm SAPIEN3 valve (Edwards Lifesciences, Irvine, California) presented with severe mitral annular calcification (MAC) and symptomatic severe mitral stenosis. She was not a surgical candidate and was referred for

Background Although radiofrequency ablation is widely used in the treatment of arrhythmias, its role in septal reduction therapy of hypertrophic obstructive cardiomyopathy (HOCM) is unclear. This meta‐analysis aimed to assess the efficacy and safety of radiofrequency septal ablation for HOCM. Hypothesis Radiofrequency septal ablation is effective and safe for relieving obstruction and improving exercise capacity in patients with HOCM. Methods A systematic review of eligible studies that reported outcomes of patients with HOCM who underwent radiofrequency septal ablation was performed using PubMed, Embase, Cochrane, ProQuest, Scopus, ScienceDirect, and Web of Science database. Pooled estimates were calculated using random‐effects meta‐analysis. Methodological quality was assessed using the Newcastle‐Ottawa scale. Publication bias and sensitivity analyses were also performed. Results Eight studies with 91 patients (mean follow‐up 11.6 months) were included. The left ventricular outflow tract (LVOT) gradient at rest decreased significantly after radiofrequency septal ablation (pooled reduction: −58.8 mmHg; 95% confidence interval [CI] −64.3 to −53.5). A reduction was also found in the provoked LVOT gradient with a pooled reduction of −97.6 mmHg (95% CI: −124.4 to −87.1). An improvement of the New York Heart Association classification (mean: −1.4; 95% CI: −1.6 to −1.2) was found during follow‐up. The change in septal thickness was minimal and not statistically significant. Two procedure‐related deaths were documented, and complete heart block occurred in eight patients. Conclusions Radiofrequency septal ablation is effective and safe for relieving LVOT obstruction and improving exercise capacity in patients with HOCM.

We present a case of inadvertent occlusion of a septal artery from being jailed during percutaneous coronary intervention of left anterior descending artery. This resulted in partial loss of the interventricular septum. Risks of side branch occlusion and bifurcation stenting are discussed.

Purpose of Review Patients with hypertrophic cardiomyopathy (HCM) who have left ventricular outflow tract obstruction (LVOTO) often experience severe symptoms and functional limitation. Relief of LVOTO can be achieved by two invasive interventions, i.e., surgery myectomy and alcohol septal ablation (ASA), leading in experienced hands to a dramatic improvement in clinical status. Despite extensive research, however, the choice of the best option in individual patients remains challenging and poses numerous clinical dilemmas. Recent Findings Invasive strategies have been recently incorporated in recommendations for the diagnosis and treatment of HCM on both sides of the Atlantic. These guidelines are based on a bulk of well-designed but retrospective studies as well as on expert opinions. Evidence now exists that adequate evaluation and management of HCM requires a multidisciplinary team capable of choosing the best available options. Summary Management of LVOTO still varies largely based on local expertise and patient preference. Following the trend that has emerged for other cardiac diseases amenable to invasive interventions, the concept of a “HCM heart team” is coming of age.

Introduction: Septal mass reduction is beneficial for hypertrophic obstructive cardiomyopathy (HOCM) patients with severe left ventricular outflow (LVOT) gradient and symptoms, with surgical myectomy or alcohol septal ablation (ASA) currently recommended in selected patients. Radiofrequency (RF) ablation of hypertrophied septum has been published as a novel method to alleviate LVOT obstruction in small populations. This study aims to investigate factors influencing clinical outcomes of radiofrequency septum ablation.Methods and Results: In this study, 20 patients with HOCM who underwent endocardial ablation were included. Echocardiography and cardiac MRI (CMR) data was collected and analyzed pre- and (or) post- procedure. Nineteen patients underwent ablation successfully, while ablation was aborted in one patient with prior RBBB due to transient complete atrioventricular block (AVB). After 6 months of follow-up, NYHA heart functional class improved from III (2 - 3) to II (1 - 2) (p < 0.001), and resting LVOT gradient was significantly reduced (87.6 ± 29.5 mmHg vs. 48.1 ± 29.7, p < 0.001). LVOT gradient reduction was significantly higher in patients with limited basal septal hypertrophy (60.9 ± 8.3 vs. 27.9 ± 7.1, p = 0.01), shorter anterior mitral leaflet (56.1 ± 6.4 vs. 20.4 ± 5.0, p < 0.01), and normally positioned papillary muscle (36.9 ± 7.1 vs. 75.0 ± 6.3, p < 0.05).Conclusions: Endocardial septal ablation appears to be a safe and effective procedure for alleviating LVOT gradient in patients with HOCM, especially in those with limited basal septal hypertrophy, shorter anterior mitral leaflet, and normal positioned papillary muscle.

Residual or recurrent symptoms after septal reduction therapy are most often related to inadequate relief of left ventricular outflow gradients. We recently encountered a 71-year-old woman with hypertrophic cardiomyopathy and prior alcohol septal ablation who had a unique constellation of findings causing her symptoms. She was found to have four potential causes for her symptoms, residual midventricular obstruction, apical distribution of hypertrophy reducing end-diastolic volume, constrictive pericarditis, and marked arterial stiffness, as reflected by aortic atherosclerosis. She underwent complete pericardiectomy, transaortic septal myectomy, transapical myectomy, and replacement of a heavily calcified ascending aorta.

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An 82-year-old woman with severe respiratory distress and limitations in functional status was found to have severe mitral valve stenosis with annular calcification and referred for transcatheter mitral valve replacement. Prophylactic alcohol septal ablation was used pre-procedurally to minimize mortality risk due to obstruction of the left ventricular outflow tract. (Level of Difficulty: Intermediate.), Graphical abstract, An 82-year-old woman with severe respiratory distress and limitations in functional status was found to have severe mitral valve stenosis with annular…

Hypertrophic cardiomyopathy (HCM) is a genetic disease and the most frequent primary cardiomyopathy, affecting 1:500 of the general population. Integrated multimodality imaging, including transthoracic echocardiography, 2- and 3‑dimensional transesophageal echocardiography, stress echocardiography, and cardiac magnetic resonance, has provided answers to questions on the management of HCM, leading to standardized protocols. The late 1990s brought the news of a nonsurgical treatment of obstruction in HCM. It is now increasingly evident that septal ablation cannot address all the mechanisms of the left ventricular outflow tract (LVOT) gradient, especially mitral valve involvement. According to American and European guidelines, surgical septal myectomy is the current gold standard treatment. However, deep septal myectomy requires specific operator and institutional experience; therefore, it should not be performed in small community hospitals but only in centers of excellence for HCM treatment. The so-called Ferrazzi technique involves cutting the fibrotic secondary chordae of the mitral valve (MV) and thus helps avoid a deep myectomy by moving the anterior mitral leaflet and the coaptation point of the MV posteriorly away from the septum. This technique, together with careful mobilization of the papillary muscles, helped us achieve excellent results since November 2015, with no mortality, resolution of the LVOT gradient, and MV preservation in all 72 patients. Owing to recent advances in the surgical treatment of hypertrophic obstructive cardiomyopathy, addressing not only the septum but also the MV, the procedure of a deep myectomy has been simplified and mitral regurgitation adequately corrected.

Transcatheter mitral valve replacement (TMVR) is an emerging treatment of mitral valve pathology in patients that are not candidates for conventional surgical approaches. Higher rates of left ventricular outflow tract obstruction (LVOTO) may occur following TMVR and its occurrence is an independent predictor of mortality. We present a case of severe mitral stenosis and annular calcification that was treated with a balloon-expandable Sapien S3 valve in the mitral position delivered through surgical port-access approach, which resulted in postoperative LVOTO. The LVOTO was successfully treated with alcohol septal ablation with immediate reduction in outflow tract gradients and long-term resolution.

In the SFHI (State Funded Healthcare Institution) Republic’s Centre for Cardiology the method of alcohol septal ablation has been introduced in 2015. The paper presents one case of a successful treatment of a patient with hypertrophic cardiomyopathy with left ventricular outflow tract obstruction treated with the use of the method of alcohol septal ablation under control of contrast enhanced echocardiography of the ablation area in the interventricular septum.

Hypertrophic cardiomyopathy (HCM) is a common genetic cardiovascular disease, causing breathlessness, chest pain, syncope and sudden death. One-year outcome of echo-guided transthoracic percutaneous laser ablation (TPLA) of the sheep interventricular septum was studied as a novel treatment to reduce the septal thickness. It may partially address the limitations of surgical myectomy and alcohol septal ablation in terms of trauma, safety, and efficacy.Twelve healthy adult sheep were randomly categorized into two groups: with and without the laser application of TPLA of the interventricular septum (IVS) at the energy level of 5 W for 3 min. Echocardiography, electrocardiography (ECG), cardiac magnetic resonance (CMR), serological and pathological examinations were performed over a 12-month follow-up.After the laser ablation all animals survived with normal cardiac function; No severe complications or bundle branch block were noted. The septal thickness (3.11 ± 1.14 vs. 8.40 ± 0.45 mm, p 0.05), regional movement of ablated IVS and longitudinal strain significantly decreased when comparing the experimental and control groups. The Troponin I level was significantly elevated after the operation, which validated immediate cardiac coagulation necrosis. On cardiac magnetic resonance (CMR) imaging, the ablated myocardium showed significant fibrosis evidenced by late gadolinium enhancement. Pathological results revealed damaged ultra-structure of the ablated myocardium and development of fibrosis.TPLA is a safe and effective minimally invasive method to reduce IVS thickness in the long term, making it a potential alternative for HOCM treatment.

In patients with resting or provoked gradients and symptoms refractory to optimal medical therapy, alcohol septal ablation or surgical septal myectomy may be considered. Given the overall comparable outcomes after ablation and myectomy, there is, for many patients, equipoise between the two procedures. Septal ablation is performed with standard angioplasty guiding catheters, guidewires, and balloon catheters. In the Euro-ASA registry, NYHA functional class fell from 2.9 ± 0.5 to 1.6 ± 0.7 and gradient from 67 ± 36 to 16 ± 21 mm Hg at mean 3.9-year follow-up after septal ablation.

We presented a case of severe aortic regurgitation and moderate mitral regurgitation s/p aortic valve replacement and mitral valve repair. Deterioration of tachyarrhythmia attacks was noted. In EP study, left lateral accessory pathway with orthodromic atrioventricular reentrant tachycardia was identified. We successfully ablated the accessory pathway by trans‐septal approach. Even though trans‐septal approach currently is a daily routine of invasive interventional electrophysiologists, in this case, we want to emphasize and illustrate the distance between true mitral annulus and coronary sinus. Unrecognizing this concept could result in efficacy and safety of catheter‐based therapy.

Background Biatrial tachycardia (BiAT) is a rare form of atrial macro-re-entrant tachycardia. Precise identification of interatrial connections and circuits of the BiAT is difficult. And incomplete understanding of the re-entrant circuit may lead to unnecessary ablation, thus increasing the risk of complications. Case summary A 69-year-old man with a history of mitral valve plasty for mitral regurgitation due to mitral valve prolapse was admitted for persistent atrial tachycardia. Electrophysiological examination using the CARTO mapping system was performed. A coherent map revealed an atrial tachycardia with a cycle length of 304 ms and a re-entrant circuit involving the left atrial septum and right atrial septum, while a ripple map suggested an epicardial interatrial connection between the right atrium and left atrium. Radiofrequency ablation on the epicardial connection successfully terminated BiAT without complications. Discussion In BiAT using both atrial septum as a re-entrant circuit, an interatrial connection or an atrial septum can be the target site for ablation. However, septal ablation can be challenging because of the risk of atrioventricular block or interatrial conduction delay, and minimal line or point ablation is needed. Coherent and ripple mapping can accurately determine the re-entrant circuit and interatrial connection of BiAT and reduce complication risks by terminating the atrial tachycardia with minimal ablation.

Background We report characteristics and outcomes of elderly patients with hypertrophic cardiomyopathy (HCM) with basal septal hypertrophy and dynamic left ventricular outflow tract obstruction. Methods and Results We studied 1110 consecutive elderly patients with HCM (excluding moderate or greater aortic stenosis or subaortic membrane, age 80±5 years [range, 75–92 years], 66% women), evaluated at our center between June 2002 and December 2018. Clinical and echocardiographic data, including maximal left ventricular outflow tract gradient, were recorded. The primary outcome was death and appropriate internal defibrillator discharge. Hypertension was observed in 72%, with a Society of Thoracic Surgeons (STS) score (8.6±6); while 80% had no HCM‐related sudden cardiac death risk factors. Left ventricular mass index, basal septal thickness, and maximal left ventricular outflow tract gradient were 127±43 g/m2, 1.7±0.4 cm, and 49±31 mm Hg, respectively. A total of 597 (54%) had a left ventricular outflow tract gradient >30 mm Hg, of which 195 (33%) underwent septal reduction therapy (SRT; 79% myectomy and 21% alcohol ablation). At 5.1±4 years, 556 (50%) had composite events (273 [53%] in nonobstructive, 220 [55%] in obstructive without SRT, and 63 [32%] in obstructive subgroup with SRT). One‐ and 5‐year survival, respectively were 93% and 63% in nonobstructive, 90% and 63% in obstructive subgroup without SRT, and 94% and 84% in the obstructive subgroup with SRT. Following SRT, there were 5 (2.5%) in‐hospital deaths (versus an expected Society of Thoracic Surgeons mortality of 9.2%). Conclusions Elderly patients with HCM have a high prevalence of traditional cardiovascular rather than HCM risk factors. Longer‐term outcomes of the obstructive SRT subgroup were similar to a normal age‐sex matched US population.

Alcohol septal ablation is a safe and effective strategy to reduce left ventricular outflow tract obstruction and improve symptoms in appropriately selected patients with obstructive hypertrophic cardiomyopathy. Invasive hemodynamic assessment and angiographic evaluation of septal anatomy are important considerations before performing septal ablation. Confirming appropriate target vessel course is necessary for optimal procedural safety and efficacy. Procedural success with septal ablation is achieved in a majority of patients with similar survival compared with isolated surgical myectomy.

BACKGROUND: The aim of this study was to evaluate short- and long-term outcomes related to dose of alcohol administered during alcohol septal ablation (ASA) in patients with hypertrophic obstructive cardiomyopathy (HOCM). Current guidelines recommend using 1-3 mL of alcohol administered in the target septal perforator artery, but this recommendation is based more on practical experience of interventionalists rather than on systematic evidence.METHODS: We included 1448 patients and used propensity score to match patients who received a low-dose (1.0-1.9 mL) versus a high-dose (2.0-3.8 mL) of alcohol during ASA.RESULTS: The matched cohort analysis comprised 770 patients (n = 385 in both groups). There was a similar occurrence of 30-day post-procedural adverse events (13% vs. 12%; p = 0.59), and similar all-cause mortality rates (0.8% vs. 0.5%; p = 1) in the low-dose group and the high-dose group, respectively. In the long-term follow-up (5.4 ± 4.5 years), a total of 110 (14%) patients died representing 2.58 deaths and 2.64 deaths per 100 patient-years in the low dose and the high dose group (logrank, p = 0.92), respectively. There were no significant differences in the long-term dyspnea and left ventricular outflow gradient between the two groups. Patients treated with a low-dose of alcohol underwent more subsequent septal reduction procedures (logrank, p = 0.04).CONCLUSIONS: Matched HOCM patients undergoing ASA with a low-dose (1.0-1.9 mL) or a high-dose (2.0-3.8 mL) of alcohol had similar short- and long-term outcomes. A higher rate of repeated septal reduction procedures was observed in the group treated with a low-dose of alcohol.

Introduction and methods Recent registry analyses including the European multicenter registry (Euro-ASA) documented a favourable long-term outcome of septal ablation (ASA/PTSMA) competitive to surgical myectomy. There is no information about the period beyond 10 years. We therefore analyzed the outcome in 120 HOCM patients (pts., mean age @ index intervention: 62±13 years) treated with ASA who survived >10 years. Results Mean CK rise during the index intervention was 537±258 U/l (reference: Conclusions The procedure-related DDD-PM rate in this septal ablation cohort including the early learning curve more than doubled the current one. Nevertheless, during ultra long-term follow up a durable clinical improvement was observed with mortality rates around 1%/year, nearly equivalent to that of 0.8% observed in normal populations. Atrial fibrillation is a frequent problem in this elderly, formerly obstructive HCM population. Funding Acknowledgement Type of funding source: None

Background Radiofrequency ablation of epicardial and mid-myocardial ventricular arrhythmias is limited by lesion depth. Objective The purpose of this study was to generate deep mid-interventricular septal (IVS) lesions using high-intensity ultrasound (US) from an endocardial catheter-based approach. Methods Irrigated US catheters (12 F) were fabricated with 3 × 5 mm transducers of 5.0, 6.5, and 8.0 MHz frequencies and compared in an ex vivo perfused myocardial ablation model. In vivo septal ablation in swine (n = 12) was performed via femoral venous access to the right ventricle. Lesions were characterized by echocardiography, cardiac magnetic resonance imaging, and electroanatomic voltage mapping pre- and post-ablation, and at 30 days. Four animals were euthanized immediately post-ablation to compare acute and chronic lesion histology and gross pathology. Results In ex vivo models, maximal lesion depth and volume was achieved by 6.5 MHz catheters, which were used in vivo. Lesion depth by gross pathology was similar post-ablation (10.8 mm; 95% confidence interval [CI] 9.9–12.4 mm) and at 30 days (11.2 mm; 95% CI 10.6–12.4 mm) (P = .56). Lesion volume decreased post-ablation to 30 days (from 255 [95% CI 198–440] to 162 [95% CI 133–234] mm3; P = .05), yet transmurality increased from 58% (95% CI 50%–76%) to 81% (95% CI 74%–93%), attributable to a reduction in IVS thickness (from 16.0 ± 1.7 to 10.6 ± 2.4 mm; P = .007). Magnetic resonance imaging confirmed dense septal ablation by delayed enhancement, with increased T1 time post-ablation and at 30 days and increased T2 time only post-ablation. Voltage mapping of both sides of IVS demonstrated reduced unipolar (but not bipolar) voltage along the IVS. Conclusion High-intensity US catheter ablation may be an effective treatment of mid-myocardial or epicardial ventricular arrhythmias from an endocardial approach.

Introduction: Septal mass reduction is beneficial for hypertrophic obstructive cardiomyopathy (HOCM) patients with severe left ventricular outflow (LVOT) gradient and symptoms, with surgical myectomy or alcohol septal ablation (ASA) currently recommended in selected patients. Radiofrequency (RF) ablation of hypertrophied septum has been published as a novel method to alleviate LVOT obstruction in small populations. This study aims to investigate factors influencing clinical outcomes of radiofrequency septum ablation. Methods and results: In this study, twenty patients with HOCM who underwent endocardial ablation were included. Echocardiography and cardiac MRI (CMR) data was collected and analyzed pre- and (or) post- procedure. Nineteen patients underwent ablation successfully, while ablation was aborted in one patient with prior RBBB due to transient complete atrioventricular block (AVB). After six months of follow-up, NYHA heart functional class improved from III (2 - 3) to II (1 - 2) (p < 0.001), and resting LVOT gradient was significantly reduced (87.6 ± 29.5 mmHg vs. 48.1 ± 29.7, p < 0.001). LVOT gradient reduction was significantly higher in patients with limited basal septal hypertrophy (60.9 ± 8.3 vs. 27.9 ± 7.1, p = 0.01), shorter anterior mitral leaflet (56.1 ± 6.4 vs. 20.4 ± 5.0, p

A 51‐year‐old woman presented with a 5‐year history of a bypass tract of a left posterior septal ablation for atrioventricular reentrant tachycardia (AVRT). Following the procedure, while swallowing even without any water or food, she felt a new onset of palpitations, and swallowing‐induced atrial tachycardia was diagnosed. We report on this patient with tachycardia induced by swallowing who received a comprehensive assessment. The swallowing‐induced atrial tachycardia deriving from the right pulmonary vein was cured by catheter ablation. In our case, the swallowing‐induced atrial tachycardia was connected with the activation of the sympathetic nervous system, which differs from typical reports of a vagal nerve reflex association.

Introduction Hypertrophic Obstructive Cardiomyopathy (HOCM) is an important cause of sudden death and heart failure, specially in young adults. Approximately 5% to 8% of patients are not suitable for transcoronary ablation, if myectomy is not feasible, Endocardial Radiofrequency Ablation of Septal Hypertrophy (ERASH) has shown acceptable efficacy and safety for left ventricular outflow tract (LVOT) gradient reduction. 20 ERASH cases have been reported in the literature. Case report 39 year old woman with diagnosis of HOCM, symptoms of dyspnea (NYHA III), and aborted sudden death as first clinical manifestation; a cardiac defibrillator was implanted. A transthoracic echocardiogram (TTE) revealed normal left ventricle (LV) ejection fraction, moderate mitral regurgitation (systolic anterior valve motion), basal inter-ventricular septal wall thickness of 20 mm generating a LVOT gradient of 51 mmHg. A coronary angiography showed inadequate septal branch anatomy to perform alcohol ablation. The patient refused myectomy. Heart Team decided to perform ERASH. Using a 3D Cardiac Mapping System and 2D Echocardiography, the basal interventricular septum received 50 Watts/50˚C radiofrequency ablation without any acute complication. Three days later, a TTE showed LVOT gradient 26 mmHg. The description of the LV mechanics is described on Table 1. Pre and post ERASH ventricular mechanics was analyzed including circumferential endocardial and mesocardial strain and strain rate, as well as longitudinal strain involved in the LV segments that received ERASH (Figure 1.) . Conclusion We report the analysis of ventricular mechanics after a successful case of ERASH, an alternative technique for treating HOCM. In our analysis, pre- ERASH longitudinal strain was significantly more negative at the basal anterior and anteroseptal segments than the other LV segments. This may be a predictor of focal LV remodeling at these segments in the future. Table 1. Pre ERASH Post ERASH Ventricular Segment Strain Strain Rate Strain Strain Rate Longitudinal Strain Basal Anteroseptal -14.4% -1.2 1/s -7% -0.6 1/s Endocardial Circumferential Strain Basal Anteroseptal -13.7% -1.9 1/s -32% -2.2 1/s Basal Anterior -44.6% -4.2 1/s -18.6% -1.6 1/s Mesocardial Circumferential Strain Basal Anteroseptal -7.7% -1.0 1/s -20.2% -1.2 1/s Basal Anterior -24.9% -1.7 1/s -13.8% -0.9 1/s Left ventricular mechanics pre and post ERASH. Abstract P1708 Figure 1.

Transcatheter alcohol septal ablation (ASA) treatment of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) is based on the existence and degree of intraventricular obstruction. Patients with significant gradient and symptoms who do not respond to optimal medical therapy are eligible to gradient reduction through a surgical (septal myectomy) or a transcatheter (alcohol septal ablation) septal reduction. The latter encompasses occlusion of a septal branch perfusing the hypertrophied septum, which is involved in the generation of obstruction, by injecting ethanol into the supplying septal branch(es). ASA has been established as a highly effective and safe method and has outnumbered the surgical gold standard. Although the technique is straightforward, patient selection and some technical details may influence the efficacy and safety of the procedure. The technique is based on echocardiographic contrast guidance, which allows accurate target septal branch selection and optimisation of the result. Published long-term results from high-volume centres have confirmed the effectiveness of ASA and have shown excellent survival, which is comparable to that in the general population. Choice and performance of the surgical or interventional treatment should be implemented in highly specialised centres in terms of a heart-team approach, taking notice of anatomic characteristics as well as comorbidities. Involvement of all cases in international registries may reveal the individual merits and indications for the surgical and interventional treatment in HOCM.

Hypertrophic cardiomyopathy is a clinically heterogeneous disease with common findings of ventricular hypertrophy, left ventricular outflow tract (LVOT) obstruction, mitral regurgitation, and diastolic dysfunction. Sometimes, the condition can lead to catastrophic cardiac events. Pregnancy can pose a larger challenge, due to medication restrictions associated with pregnancy. We report a case of a 43-year-old pregnant woman presenting with symptomatic hypertrophic obstructive cardiomyopathy (HOCM). As her pregnancy progressed, her HOCM worsened both symptomatically and by objective echocardiographic data. These changes continued despite optimized medical therapy. After an in-depth discussion with both the patient and family, we proceeded with alcohol septal ablation, which was successful in both reducing her LVOT gradient and her symptoms. Her pregnancy was overall uneventful, and both she and her child are doing well more than 4 years from the date of the procedure.

We presented a 77-year-old man with hypertrophic obstructive cardiomyopathy applied with flail tricuspid leaflet and severe tricuspid regurgitation leading to right heart failure 2 months after the failed septal ablation. The ruptured anterior tricuspid papillary muscle resulted from infarction of the base of anterior papillary muscle of the right ventricle (RV) confirmed by magnetic resonance imaging. As the septomarginal band is frequently lit up by intracoronary contrast that particular attention should be paid to the RV papillary muscles. And, if the papillary muscles or the RV free wall is brightened, then the use of that septal artery should be avoided.

Different studies have shown a good long-term survival with improvement of symptoms and hemodynamics after percutaneous septal ablation (PTSMA), similar to myectomy considered to be the therapeutic “gold standard” for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). Furthermore, desobliteration of left ventricular (LV) outflow may modify features of the disease considered to be risk-relevant, such as magnitude of LV hypertrophy, outflow gradient, and left atrial (LA) size. The aim oft this study was to examine predictors of long-term mortality in a large cohort of patients with HOCM treated with PTSMA. 497 consecutive patients with symptomatic HOCM (mean age 55.4 ± 14.4 years, NYHA class: 2.9 ± 0.4) who underwent PTSMA between 1996 and 2014 were studied. Periprocedural mortality was 1% (five patients). During a follow-up time of 64.5 ± 53.2 months (range 0.1–207), 51 patients died, of these 25 due to cardiovascular problems, while 26 deaths were attributed to non-cardiac causes. Overall survival rates were 89.4% (± 1.7) after 5 and 80.6% (± 2.7) after 10 years. Among the baseline variables, advanced age, recurrent syncope, and magnitude of LV thickening were risk markers correlated to long-term post-procedural survival. The only mortality predictor that could be identified during follow-up was post-procedural NYHA class. Neither the other classical HCM risk markers nor other clinical or echocardiographic parameters predicted cardiac or all-cause mortality in this cohort. Our findings suggest that the risk profile after septal ablation may differ from that of HOCM patients without an outflow desobliteration.