Journal of Invasive Cardiology

ABSTRACT: A 52-year-old man was referred to the cardiology outpatient service with exertional angina and shortness of breath due to hypertrophic obstructive cardiomyopathy. He underwent transcoronary ethanol septal ablation (TESA) with successful procedural outcome. The patient returned to hospital with a 3-week history of intermittent fever and a positive blood culture showing Staphylococcus aureus, sensitive to flucloxacillin. Transoesophageal echocardiography on admission demonstrated vegetation on interventricular septum and a repeated scan 10 days later demonstrated Doppler flow across the interventricular septum, confirming the presence of a small ventricular septal defect. This patient was successfully managed with 6 weeks of intravenous antibiotics and remained well at 1-year follow-up.

J INVASIVE CARDIOL 2011;23:348–350

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Case Report

A 52-year-old man was referred to the cardiology outpatient service with Canadian Cardiovascular Society Functional Class¹ II exertional angina and New York Heart Association² III exertional shortness of breath. No major cardiac risk factors apart from a 10 pack-year smoking history were identified, with normal coronary artery noted on multislice computed tomographic coronary angiography. Subsequently, echocardiography demonstrated 1.6 cm septal hypertrophy with systolic anterior motion of the mitral valve and mild mitral regurgitation. The peak gradient across the left ventricular outflow tract (LVOT) was measured at 108 mmHg.

Due to the presence of significant symptoms and evidence of hypertrophic obstructive cardiomyopathy (HOCM), this patient was brought forward for transcoronary alcohol septal ablation. The third septal branch was identified as the vessel of interest, confirmed by gradient drop after occluding the vessel by a balloon as well as periprocedural echocardiogram with saline contrast injection (Figures 1, 2A, and 2B). This vessel was successfully injected with 2.5 ml of 100% ethanol (Figure 1). The LVOT gradient dropped from 92 to 15 mmHg before and after the ethanol injection; the post-premature ventricular contraction gradient also dropped from 207 to 105 mmHg.