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[Obstructive cardiomyopathy and stenosing coronary atherosclerosis. Apropos of 5 cases]
Insights
This study reports on five cases of hypertrophic obstructive cardiomyopathy and coronary artery disease, finding the combination is not uncommon. Management strategies are discussed, suggesting simultaneous surgical correction may be beneficial.
Area of Science:
- Cardiology
- Cardiovascular Surgery
Background:
- Hypertrophic obstructive cardiomyopathy (HOCM) and coronary artery disease (CAD) are distinct cardiovascular conditions.
- The co-occurrence of HOCM and CAD may be more frequent than previously thought.
Observation:
- Five patients (2 male, 3 female) aged 27-70 years presented with HOCM and significant CAD.
- Diagnostic criteria for HOCM included systolic murmurs, specific pulse tracings, echocardiographic findings (SAM, ASH), and pressure gradients.
- Coronary angiography revealed severe stenoses (>70%) in major coronary arteries in all patients.
Findings:
- Four patients experienced angina, while one was asymptomatic.
- Two patients underwent coronary artery bypass grafting (CABG) without myomectomy; three were managed medically.
- Follow-up (8 months to 6 years) showed favorable outcomes in four patients, with one experiencing moderate angina despite medical management.
Implications:
- The association between HOCM and CAD appears to be fortuitous and potentially underestimated.
- Optimal long-term management and prognosis for this combined condition remain unclear.
- Simultaneous surgical correction (myomectomy and CABG) is proposed as a logical approach when medical therapy fails, despite potential operative risks.
Abstract:
Five cases of hypertrophic obstructive cardiomyopathy with coronary artery disease are reported; 2 males and 5 females, aged 27, 49, 64, 67, and 70 years respectively. Four patients had angina, the other being asymptomatic. The diagnosis of hypertrophic obstructive cardiomyopathy was based on the presence of at least 4 of the following 5 signs: an ejectional systolic murmur, an external carotid pulse tracing showing a second endsystolic peak, an echocardiogramme showing both systolic anterior motion of the mitral valve and asymmetrical septal hypertrophy biloculation and/or disaxation of the left ventricular cavity on selective angiography, and a spontaneous or provoked intraventricular pressure gradient of over 30 mm Hg. Coronary angiography showed one or more stenoses of over 70% on at least one of the three main coronary arteries in all patients. Two of the 5 patients underwent coronary artery bypass surgery without myomectomy; the remaining 3 patients were treated medically. All patients have been followed up for periods ranging from 8 months to 6 years (average: 4 years) with a favourable outcome in 4 of them who are currently asymptomatic; the other patient has moderate angina (non-operated, treated with propranolol). The frequency of the association of hypertrophic obstructive cardiomyopathy and coronary artery disease was initially underestimated, but in fact it does not appear to be uncommon. The association would seem to be fortuitous. The long-term prognosis is not known and the management is not codified. It would seem logical to propose simultaneous surgical correction of the two conditions by myomectomy and coronary bypass surgery when anatomically possible, when beta blocker therapy fails, despite a relatively high operative risk, according to the few published cases.