Unusual cause of recalcitrant epistaxis

Nosebleeds are among the most familiar presentations to the emergency department as well as otorhinolaryngologic outpatient services. Bleeding from nasal septal branches of the anterior ethmoid artery (AEA) is common and can be effectively controlled endoscopically. However, the bleeding from a pseudoaneurysm involving the nasal septal branches of AEA is extremely rare and can be troublesome to control using endoscopic methods. We report an adult patient presenting with profuse nasal bleeding postroad traffic accident due to the formation of AEA septal branch pseudoaneurysm. The patient required repeated nasal packing, and the diagnosis was revealed using digital subtraction angiography. Since profuse active bleeding precluded endoscopic visualisation, an external approach had to be adopted to ligate the AEA to control the bleeding. We discuss the management options and nuances for this rare cause of the troublesome nasal bleeding.

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.

Targeted septal branch microcirculatory embolization with tris-acryl gelatin microspheres in hypertrophic obstructive cardiomyopathy

Background Alcohol septal ablation (ASA) has been shown to be an effective treatment in patients with hypertrophic obstructive cardiomyopathy (HOCM) who are refractory to medical treatment. ASA may cause some life-threatening complications including conduction disturbances, hemodynamic compromise, ventricular arrhythmias, distant and massive myocardial necrosis. Tris-acryl gelatin microspheres provide consistent and predictable results for effective targeted microcirculatory embolization. Purpose We aimed to report our initial experience in tris-acryl gelatin microspheres for septal ablation in HOCM. Methods Microspheres are biocompatible, hydrophilic, non-resorbable microspheres which are available in a range of calibrated sphere sizes. In our method, after the cannulation of the left anterior descending by a 6F-7F guiding catheter, a 0.014-inch guidewire is introduced through the catheter and advanced into the septal branch. This septal artery is selectively cannulated with a 4F catheter over the guidewire. Selective angiography of the septal artery is performed to show the anatomy and collateral branches to other coronary arteries. Contrast echocardiography is performed to make sure that the pertinent septal artery is the target vessel supplying the hypertrophied septum. A microcatheter is then advanced deep enough into the septal artery through the 4F catheter. Microspheres/contrast solution infused slowly under fluoroscopic guidance into the targeted septal branches initially using coronary arteriolar sized small particles (diameter 100–300 μm); then the particle size was stepped up to larger particles (diameter 300–500 μm) until a complete block of the arteriolar flow is achieved. Results Septal ablation with tris-acryl gelatin microspheres was performed in 6 patients (mean age = 47.8±11.5; 5 males). Immediately after the procedure peak left ventricular outflow (LVOT) gradient reduced significantly both for direct catheter (69.0±13.8 vs. 8.2±3.7 mmHg, P<0.001) and Doppler echocardiographic measurements (78.8±19.9 vs. 12.0±5.1 mmHg, P<0.001). Post-procedure peak serum CK- MB fraction concentration was 82±22 ng/ml (reference range is 0 - 4.9 ng/mL) and peak serum troponin T concentration was 1.2 ng/ml [(interquartile range, 0.4–1.4), (reference range is 0 - 0.017 ng/mL)]. LVOT tract gradient reduction persisted after 6 months follow-up. There was no significant complication during the procedure and within a 6 months follow-up period. Conclusions The novel strategy by targeted septal branch microcirculatory embolization with tris-acryl gelatin microspheres seems to be an efficient and safe approach to HOCM. Further experience is needed in order to assess the long-term efficacy and safety of this technique. Funding Acknowledgement Type of funding source: None

P706 LMCA and LAD coronary ectasia in an asymptomatic young patient reassessment with multimodality imaging after 17 years

A 25 years old male patient was referred to an advanced center because of 2/6-degree systolo-diastolic murmur heard at meso-cardiac area during his pre-military routine examination. ECG revealed T wave inversions at standard D1 to D3 and precordial V1 to V4 leads, treadmill was non-diagnostic for ischemia. In his transthoracic echocardiogram, measurement of heart chambers and wall thicknesses were within normal range with normal wall motion of the left ventricle, EF was 55%. 2D and color-Doppler echocardiography revealed a cystic structure with venous flow in it at the right ventricular apex, and created a suspicion of a fistula. Myocardial perfusion scintigraphy showed ischemia at the apical sections of the septal wall. He underwent coronary angiography, LMCA and proximal LAD were ectatic, LAD ectasia was in consistent with the first septal branch, circumflex (Cx) and right coronary artery (RCA) angiograms were normal. LAD flow was examined and no fistula was detected. Right and left ventriculography revealed normal ventricular functions, oxygen saturations were 70.9% in pulmonary artery, 70.4% in right ventricle, 72.9% in right atrium, and 97.4% in the aorta. Pulmonary capillary wedge pressure was 10 mmHg, pulmonary artery pressure 10/26/5 mmHg, right ventricular pressure 13/6 mmHg, left ventricular pressure 120/0/8 mmHg. Further investigations for etiology and congenital malformations were planned and the patient was discharged with oral anticoagulant therapy. The patient had no contact with the outpatient clinic for 17 years. At the 17th year of the diagnosis he was called and reevaluated. He was still asymptomatic and oscultation findings were the same. Transthoracic 2D and 3D and color-Doppler echocardiography revealed the same cystic structure at the right ventricular apex, but this time with no-flow. Coronary CT angiography was performed, LMCA was ectatic and the diameter was 8.1 mm, proximal LAD was ectatic and the diameter was 6 mm, ectasia was in continuous with the first septal branch. The ectatic septal branch was at the apical level of the right ventricle, appearing like a cystic structure with a diameter of 2.8 cm, and the lack of contrast enhancement was thougt to be in consistent with thrombus formation. Cx and RCA artery calibrations were found to be normal. In order to confirm the diagnosis of thrombus formation, MR angiography was performed. Perfusion MRI showed no evidence of thrombus in the ectatic septal branch. Abstract P706 Figure.