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[The therapeutic focus in severe hypertrophic obstructive cardiomyopathy with multivessel coronary disease]
J C Tascón Pérez1, A A González-Trevilla, M A Gutiérrez
1Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid.
Insights
This study presents a combined therapy for severe hypertrophic obstructive cardiomyopathy and coronary artery disease. A-V sequential pacing and coronary angioplasty with stenting effectively treated a patient, reducing surgical risks.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Electrophysiology
Background:
- Severe hypertrophic obstructive cardiomyopathy (HOCM) combined with coronary artery disease (CAD) significantly increases surgical risks, particularly in elderly patients.
- Managing these co-existing conditions presents a complex clinical challenge due to elevated morbimortality.
Observation:
- A 68-year-old female patient with functional class IV HOCM experienced refractory angina and dyspnea despite maximal beta-blocker therapy.
- Cardiac catheterization revealed severe stenosis in the left circumflex and right coronary arteries, alongside moderate left anterior descending disease, in addition to severe HOCM.
Findings:
- The patient underwent successful percutaneous coronary intervention (PCI) with stenting of the affected coronary arteries.
- Subsequent implantation of a DDD-R pacemaker for A-V sequential pacing significantly reduced the left ventricle outflow tract gradient.
- Combined therapy demonstrated excellent short-term and six-month follow-up results, including improved hemodynamic parameters and echocardiographic findings.
Implications:
- A-V sequential pacing and coronary angioplasty with stenting represent a viable combined therapeutic strategy for patients with both HOCM and CAD.
- This combined approach offers a potentially safer alternative to surgery for high-risk patients, improving clinical outcomes.
- Further research may validate this combined therapeutic modality for broader clinical application in managing complex cardiac conditions.
Abstract:
The association of severe hypertrophic obstructive cardiomyopathy and coronary artery disease increases surgical morbimortality, even more in patients over 65 years. We describe a combined therapeutic approach to these diseases. A 68-year-old woman with a diagnosis of hypertrophic obstructive cardiomyopathy was in functional class IV for angina and dyspnea despite 360 mg of propranolol a day. An echocardiogram and a complete cardiac catheterization were performed under betablocker therapy, confirming a severe hypertrophic obstructive cardiomyopathy and revealing severe stenosis in the proximal left circumflex and the proximal right coronary arteries, and a moderate lesion in the mid-left anterior descendent. They were both treated with balloon PTCA, and a 3 x 15 mm stent was placed in the circumflex and a 3.5 x 20 mm stent in the right coronary, with an excellent angiographic result. A basal hemodynamic study was then performed and A-V sequential pacing was attempted, achieving a significant decrease in the left ventricle outflow tract gradient. A DDD-R pacemaker was implanted. Echocardiographic study was performed post-implantation, and follow-up was made six months later with a new coronary angiography, hemodynamic study and a Doppler echocardiogram. At the present time A-V sequential pacing as a therapeutic option for hypertrophic obstructive cardiomyopathy and coronary angioplasty and stenting for the treatment of coronary artery disease are sufficiently established and supported to be offered as a combined therapy to patients suffering from both diseases, specially those with a higher surgical risk.