Rescue alcohol septal ablation in sepsis with multiorgan failure

Area of Science:

• Cardiology
• Interventional Cardiology

Background:

• Hypertrophic cardiomyopathy (HCM) can lead to severe left ventricular outflow tract (LVOT) obstruction.
• Sepsis secondary to cholangitis presents a complex clinical scenario in HCM patients.

Observation:

• A 55-year-old male with HCM presented with sepsis and cholangitis, initially unresponsive to medical management.
• Following successful endoscopic retrograde cholangio-pancreatography (ERCP) for CBD stone retrieval, the patient developed a massive upper gastrointestinal bleed, leading to shock and a critically low mean arterial blood pressure (44 mm Hg).
• Echocardiography revealed a significant resting LVOT gradient of 90 mm Hg.

Findings:

• Emergency alcohol septal ablation (ASA) was performed due to the high LVOT obstruction and hemodynamic instability.
• Immediately post-ASA, a marked decrease in LVOT obstruction and a rise in systemic arterial pressures were observed.
• The patient was discharged after 10 days of antibiotic therapy with a residual LVOT obstruction of 28 mm Hg.

Implications:

• Alcohol septal ablation is a viable and effective emergency treatment for severe LVOT obstruction in hemodynamically unstable hypertrophic cardiomyopathy patients.
• This case underscores the importance of prompt intervention for obstructive HCM in critically ill patients.
• Multidisciplinary management is crucial for addressing complex comorbidities like sepsis in patients with advanced cardiac conditions.