Syndrome of Reversible Cardiogenic Shock and Left Ventricular Ballooning in Obstructive Hypertrophic Cardiomyopathy

Background Cardiogenic shock from most causes has unfavorable prognosis. Hypertrophic cardiomyopathy (HCM) can uncommonly present with apical ballooning and shock in association with sudden development of severe and unrelenting left ventricular (LV) outflow obstruction. Typical HCM phenotypic features of mild septal thickening, outflow gradients, and distinctive mitral abnormalities differentiate these patients from others with Takotsubo syndrome, who have normal mitral valves and no outflow obstruction. Methods and Results We analyzed 8 patients from our 4 HCM centers with obstructive HCM and abrupt presentation of cardiogenic shock with LV ballooning, and 6 cases reported in literature. Of 14 patients, 10 (71%) were women, aged 66±9 years, presenting with acute symptoms: LV ballooning; depressed ejection fraction (25±5%); refractory systemic hypotension; marked LV outflow tract obstruction (peak gradient, 94±28 mm Hg); and elevated troponin, but absence of atherosclerotic coronary disease. Shock was managed with intravenous administration of phenylephrine (n=6), norepinephrine (n=6), β‐blocker (n=7), and vasopressin (n=1). Mechanical circulatory support was required in 8, including intra‐aortic balloon pump (n=4), venoarterial extracorporeal membrane oxygenation (n=3), and Impella and Tandem Heart in 1 each. In refractory shock, urgent relief of obstruction by myectomy was performed in 5, and alcohol ablation in 1. All patients survived their critical illness, with full recovery of systolic function. Conclusions When cardiogenic shock and LV ballooning occur in obstructive HCM, they are marked by distinctive anatomic and physiologic features. Relief of obstruction with targeted pharmacotherapy, mechanical circulatory support, and myectomy, when necessary for refractory shock, may lead to survival and normalization of systolic function.

Alcohol Ablation for Ventricular Tachycardia

Catheter-based radiofrequency (RF) ablation is an effective, well-established therapy for ventricular tachycardia (VT). However, a large number of patients still have recurrences, particularly those with substrates arising from intramural locations that are inaccessible through endo- or epicardial catheter approaches. Several unconventional ablation techniques have been proposed to treat RF-refractory VT, including transarterial coronary ethanol ablation and retrograde coronary venous ethanol ablation. We review the evidence regarding the mechanisms, procedural aspects, and alcohol ablation outcomes for ventricular arrhythmias.

Characteristics and Outcomes of Elderly Patients With Hypertrophic Cardiomyopathy

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/m 2 , 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.

The first clinical experience of Marshall’s vein alcohol ablation in complex treatment of persistent atrial fibrillation

This article describes the first in Ukraine clinical experience of alcohol ablation of Marshall’s vein in the complex interventional treatment of persistent atrial fibrillation (AF). Current scientific data suggest that when drug therapy is ineffective, ablation of AF substrate is a most important stage in the treatment of arrhythmia, as well as optimal method of control and prevention of further cardiovascular events. The standard treatment for paroxysmal AF is radiofrequency ablation (RFA) with electrical isolation of the pulmonary veins (PVI). However, due to the involvement of other pathogenetic mechanisms, a sole PVI is less effective in persistent forms of arrhythmia. For example, in persistent AF forms pathological electrical activity often occurs beyond the pulmonary veins. In particular, it can be observed in the area of ​​the posterior wall of the left atrium and mitral isthmus resulting in perimitral atrial flutter. RFA in this area can reduce the rate of arrhythmia recurrence. However, achieving a stable bidirectional conduction block in the area of ​​lateral mitral isthmus with endocardial RFA is technically challenging. An option to improve the effectiveness of RFA in this case, apart from epicardial RFA in the distal coronary sinus, is an alternative method, i.e. alcoholic ablation of Marshall’s vein by introducing ethanol into its lumen, occluded by a balloon. The presented clinical case shows combined variant of persistent AF minimally invasive treatment using alcoholic Marshall’s vein ablation and RFA with PVI target. Key words: atrial fibrillation, radiofrequency ablation, alcoholic ablation, Marshall vein, clinical case.

Late Complications after Alcohol Septal Ablation in a Patient with Hypertrophic Obstructive Cardiomyopathy

(1) Background: Complete atrioventricular block is a well-known complication of alcohol ablation as a septal reduction therapy, implemented in selected patients with hypertrophic obstructive cardiomyopathy (HOCM). It usually occurs during or immediately after the intervention. Rare cases of late complete atrioventricular block (CAVB) have been reported, but data are still scarce in the literature regarding this issue. (2) Case report: We report the case of a 70-year-old male patient, with mild aortic stenosis, but with a significantly degenerated valve and perivalvular tissue, and a nonspecific intraventricular conduction delay, which developed intensely symptomatic CAVB, four months after alcohol septal ablation (ASA) for HOCM, along with left ventricular pressure gradient recurrence. Both problems were resolved by implantation of a dual chamber pacemaker, with pacing optimization to a short atrioventricular interval, along with a maximal tolerated betablocker therapy. With the description of the patient’s treatment and evolution in comparison with other reports and studies, this case report highlights the fact that a close clinical, electrical and echocardiographic surveillance is warranted for this kind of patients, as late CAVB may be a life-threatening complication. Previous electrical conduction problems and degenerated aortic valve and perivalvular tissue may be predisposed for this type of complication, independent of betablocker therapy. This treatment has several other beneficial effects and thus it should not be interrupted after the procedure.

Abstract 14910: Role of 3.3fr Mapping Catheters in Defining and Ablating Mechanisms of Ventricular Arrhythmias: A Multicenter Experience

Introduction: Ventricular arrhythmia (VA) mechanisms arising from the crux, summit, and epicardium are often not accessible from the endocardium. The 3.3Fr multipolar mapping catheters (3FMC) (Map-iT, Access Point Technologies, Rogers, MN) can be used to map deep within the coronary sinus (CS) branches and other locations difficult to access with standard catheters. Objective: We present a case series of and techniques for VA ablations guided by the 3FMC. Methods: We retrospectively reviewed VA ablations at 3 centers to describe the utility of the 3FMC in diagnosis and ablation of the arrhythmia. Results: We reviewed 33 patients who underwent VA ablations guided by the 3FMC. Patients (age 59.0 ± 15.4 years, 72% male, LVEF 41.5 ± 10.3%, 93% non-ischemic) had ventricular tachycardia (32%) or high-burden PVCs (68%). The 3FMC was used to interrogate the epicardium via the coronary sinus branches allowing interrogation of the LV crux (Fig. A) and LV summit (Fig. B). Early potentials in the poster-septal branch of CS guided alcohol ablation to focal site in septum not reachable by traditional catheters. Continuous signal on the 3FMC in the posterolateral branch of CS elucidated microreentry and guided more extensive epicardial ablation. Overall, the 3FMC measured signals 18.7 ± 11.3ms early and diagnosed 75% focal, 10% micro-reentrant, and 15% macro-reentrant VAs. Ablation was successful in 76% of cases. Conclusions: High definition mapping with the 3FMC allows diagnosis of VA mechanisms in locations not easily reachable by traditional catheters. Improved mapping of the CS branches enables interrogation and ablation planning of epicardial, summit, and crux VAs and may increase the likelihood of successful VA ablation.