Since hypertrophic obstructive cardiomyopathy complicated by intractable symptoms has heterogeneous phenotypic expressions, it is extremely important to tailor the therapy specifically for each patient. Therefore, a careful clinical evaluation including magnetic resonance and echocardiography should be performed prior to making decision about possible septal reduction therapy. 1
Clinical experience suggests that severe left ventricular obstruction might be present not only in the left ventricular outflow tract, but also deeper in the mid-ventricular segment. Currently, we recommend surgical myectomy in all highly symptomatic patients with a mild septal thickness and long mitral leaflets, redundant chordae, significant papillary muscle abnormalities, and/or mid-ventricular cavity obstruction. 1 On the other hand, patients with less complex left ventricular pathology and septal thickness localized optimally only into the basal septum are better suited to alcohol septal ablation. 1
For better visualization of left ventricular pathology and to improve decision making about a type of septal reduction, a three-dimensional printing of the heart might be performed using data from cardiac computed tomography (CT) examination. 2 3 4 ( Figs. 1 and 2 ) Additionally, different colors can delineate the area with maximal obstruction done by anterior mitral leaflet and hypertrophied basal septum. Such three-dimensional model might be a new source of information for heart teams in a process of planning the optimal reduction therapy.
Fig. 1.
Three-dimensional model of the heart with colored both the anterior mitral leaflet (pink) and hypertrophied basal septum (blue).
Fig. 2.
The anterior mitral leaflet (pink) is lifted up; the basal septum (blue) narrows the left ventricular outflow tract with aortic valve in the background (asterix).
References
- 1.Veselka J, Anavekar N S, Charron P.Hypertrophic obstructive cardiomyopathy Lancet 2017389(10075):1253–1267. [DOI] [PubMed] [Google Scholar]
- 2.Cooper R M, Raphael C E, Liebregts M, Anavekar N S, Veselka J. New developments in hypertrophic cardiomyopathy. Can J Cardiol. 2017;33(10):1254–1265. doi: 10.1016/j.cjca.2017.07.007. [DOI] [PubMed] [Google Scholar]
- 3.Bartel T, Rivard A, Jimenez A, Mestres C A, Müller S.Medical three-dimensional printing opens up new opportunities in cardiology and cardiac surgery Eur Heart J 2017; [ Epub ahead of print ] 10.1093/eurheartj/ehx016 [DOI] [PubMed] [Google Scholar]
- 4.Veselka J. How to treat obstruction in patients with hypertrophic cardiomyopathy. Int J Angiol. 2015;24(02):121–126. doi: 10.1055/s-0034-1396900. [DOI] [PMC free article] [PubMed] [Google Scholar]