case study hypertrophic cardiomyopathy
DESCRIPTION
Overview of HCM, including alcohol septal ablation and a real-life treatment courseTRANSCRIPT
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IN
CASE STUDY
HYPERTROPHIC CARDIOMYOPATHY:
One Patient’s Course of TreatmentJanette LaFroscia
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CASE STUDY OVERVIEW
• Review of HCM• Characteristics• Symptoms• Treatments
• Alcohol Septal Ablation• General overview
• A Patient with HOCM
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CASE STUDY
HYPERTROPHIC CARDIOMYOPATHY
• HCM, HOCM, IHSS, ASH
• Definition: abnormal thickening of the myocardium• Typically involves the septum• Decreased LV chamber size with narrowed
LVOT• Displacement of Mitral valve
• Causes decrease in CO and BP
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CASE STUDY
HYPERTROPHIC CARDIOMYOPATHY
• Can lead to:• Dynamic LVOT obstruction• MR• Diastolic dysfunction• Myocardial ischemia• Arrhythmias: SVTs and VT/VF/SCA
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CASE STUDY
HYPERTROPHIC CARDIOMYOPATHY
• Symptoms:• Dyspnea• Fatigue• Chest pain• Dizziness• Syncope• SCA
• Diagnosed with: H&P, Echo, EKG, MRI, and/or Left Heart Catheterization
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CASE STUDY
• HYPERTROPHIC CARDIOMYOPATHY
• Treatments:• Medications- Beta Blockers, Ca Channel
Blockers, Disopyramide• Surgery- Septal myectomy• DDD PPM- force RVA pacing with
Negative AV Hysteresis (Class IIb)• ICD- SCA (Class I); positive family history,
NSVT, syncope, decreased BP with exercise, LV > 30mm (Class IIa)
• Alcohol Ablation
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CASE STUDY
ALCOHOL SEPTAL ABLATION
• Definition: a percutaneous, minimally-invasive procedure to relieve symptoms and improve QOL with severely symptomatic patients
• Introduced in 1994
• Creates a small, controlled MI• Damages the area causing obstruction, leading to
an more opened LVOT and improved CO
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CASE STUDY
ALCOHOL SEPTAL ABLATION
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CASE STUDY
A PATIENT WITH HOCM
• 76 yo female• Admitted with increasing DOE times several
months, worsening in the previous week
• PMH• HOCM- currently taking Atenolol (Tenormin)• HTN• Severe MR• Remote tobacco• EtOH• No family history of cardiac disease
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CASE STUDY
PATIENT ASSESSMENT
• ACS ruled out• No positive cardiac enzymes
• PE unlikely• No risk factors
• Diagnosis: CHF from HOCM and MR
• Treatment Plan: Left Heart Cath with Alcohol Septal Ablation
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CASE STUDY
PRE PROCEDURE ECHO FINDINGS
Prominent LVH with hyperdynamic LV function (EF > 75%), severe LVOT gradient, severe MR
Demo images
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CASE STUDY
LEFT HEART CATH PROCEDURE
• No significant coronary disease• Initial measurement of LV gradient: 130
mmHg• Gradient after injection of 2.5 ml ethanol: 30
mmHg
Demo image
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CASE STUDY
PERI- AND POST-OP COURSE
• During procedure, patient developed RBBB• Temporary pacing wire inserted
• Patient sent to CCU• Did not need pacing overnight (VVI 40),
and temp wire removed
• Next day, patient sat up in bed and had long period of ventricular asystole, followed by ventricular escape rhythm of 20bpm
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CASE STUDY
DIAGNOSIS
• Paroxysmal AV Block
• Patient given Dopamine infusion and Atropine bolus• Return of 1:1 AV conduction
• Temp wire reinserted in right IJ, set at VVI 70bpm
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CASE STUDY
OUTCOME
• Patient received dual chamber pacemaker • STJ Zephyr• Tendril STS leads, 46cm and 52 cm• Normal sensing and capture threshold
measurements
• Temp wire removed under fluoro to ensure new leads were not dislodged
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CASE STUDY
SUMMARY
• HCM is a rare, sometimes lethal condition
• Alcohol septal ablation is an effective procedure for the treatment of symptomatic HCM
• Complications can occur with any procedure