P135 Transcoronary ablation of septal hypertrophy for hypertrophic obstructive cardiomyopathy in a patient with severe aortic valve stenosis.
F.H.Gietzen, J.Schümmelfeder, F.von Hoch, R.Schamberger, J.Brunn, B.Schumacher, S.Kerber
Herz- und Gefäß-Klinik Bad Neustadt/Saale, Fachbereich Kardiologie, Bad Neustadt/Saale.

Transcoronary ablation of septal hypertrophy (TASH) is a catheter interventional therapy for hypertrophic obstructive cardiomyopathy (HOCM). However, for reduction of septal thickness, elimination of outflow obstruction and improvement of symptoms, the injection of 95% ethanol into a septal branch as well as the induction of a septal necrosis (~3% of the left ventricular mass) had to be accepted. Consideration had to be given predominantly to the possibility of weakening a failing heart with subsequently enhanced risk of progressive left ventricular dysfunction.

We report on TASH in a 75 y. old women with HOCM and severe aortic valve stenosis (aortic valve area 0.4 cm2). Surgery as a first line therapy could not be performed because of an unusual severe calcification of the aortic and mitral valve ring as well as of the ascending aorta. In this situation cross-clamping and cannula placement for aortic valve replacement and myectomy would have carried an unacceptable risk of an early adverse outcome. Severe symptoms (NYHA functional class IV), life-threatening reduction of cardiac index (0.8 l/m2/min!), basal septal thickness (20 mm), SAM septum contact and a critical left ventricular outflow obstruction (30 mmHg at rest despite aortic valve stenosis and elevation in afterload) argued for a palliative catheter intervention. TASH (occlusion of the first septal perforator artery by injection of 2.0 ml 95% ethanol) led to a complete elimination of left ventricular outflow obstruction (at rest and after provocation), a reduction in basal septal thickness (15 mm) and a significant subjective improvement. Three months after intervention the pt. remains free of hospital re-admission, angina or syncope. She takes care for herself and dyspnoea does no longer interfere with intended daily activities (NYHA functional class III) despite an unchanged severe aortic valve stenosis and the induction of a septal necrosis (peak CK-activity 212 U/L).

Conclusion: This case report seems to be another piece of evidence for the benefits of TASH in pts. with HOCM and severe symptoms. TASH improves global left ventricular function even in a pt. with severe cardiac co-morbidity and indicated cardiac surgery for symptomatic aortic valve stenosis.