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Visualisation of ablated septal myocardium using myocardial contrast echocardiography in hypertrophic obstructive cardiomyopathyKeywords: Images in cardiology

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A 59 year old woman presented with exertional dyspnoea and presyncope. Cross sectional and Doppler echocardiography revealed asymmetric septal hypertrophy, systolic anterior movement of the anterior mitral leaflet, and left ventricular outflow obstruction with a pressure gradient of 140 mm Hg. She was diagnosed with hypertrophic obstructive cardiomyopathy (HOCM), and had been treated with 300 mg of disopyramide per day. Nevertheless, her symptoms and pressure gradient had been refractory, so she was scheduled for percutaneous transluminal septal myocardial ablation (PTSMA). The first major septal branch of the left anterior descending artery was then probed with a 0.014 inch thick guide wire, andcatheterised with a 1.5 mm angioplasty balloon catheter; 5 ml of absolute alcohol was then slowly injected into the septal artery. After the procedure, the pressure gradient decreased from 140 mm Hg to 50  mm Hg.

On the fifth postoperative day, echocardiographic studies were carried out again. A reduction in the pressure gradient remained, and new wall motion dyskinesia could be seen in the basal septum. We performed myocardial contrast echocardiography with ECG triggered end diastole harmonic power Doppler technique using intravenous Levovist (a saccharide based transpulmonary echo contrast agent; Schering AG) before and after PTSMA. The preoperative image demonstrated homogeneous myocardial opacification (left). In contrast, the postoperative image showed the contrast defect at the basal septum which was consistent with 99mTc- MIBI myocardial perfusion imaging (right).

PTSMA is an effective procedure for some HOCM patients who are symptomatic despite sufficient drug treatment. We suggest that myocardial contrast echocardiography using the ECG triggered harmonic power Doppler technique is useful for detecting ablated septal myocardium, as well as scintigraphy.