Visualization of transcoronary ablation of septal hypertrophy in patients with hypertrophic obstructive cardiomyopathy: a comparison between cardiac MRI, invasive measurements and echocardiography.

Objective: Hypertrophic obstructive cardiomyopathy (HOCM) is treated by surgical myectomy or transcoronary ablation of septal hypertrophy (TASH). The aim of this study was to visualize the feasibility, success and short-term results of TASH on the basis of cardiac MRI (CMR) in comparison with cardiac catheterization and echocardiography.

Methods: In this in vivo study, nine patients with HOCM were treated with TASH. Patients were evaluated by transthoracic echocardiography, invasive cardiac angiography and CMR. Follow-up examinations were carried out after 1, 3 and 12 months. MR imaging was performed on a 1.5-T scanner. All images were processed using the semiautomatic Argus software and were evaluated by an attending thoracic radiologist and cardiologist.

Results: The echocardiographic pressure gradient (at rest) was 69.3 +/- 15.3 mmHg before and 22.1 +/- 5.7 mmHg after TASH (P < 0.01, n = 9). The flux acceleration over the aortic valve examined (V (max)) was 5.1 +/- 0.6 m/s before and 3.4 +/- 0.3 m/s after the TASH procedure (P < 0.05). Also, there was a decrease of septum thickness from 22.0 +/- 1.2 to 20.2 +/- 1.0 mm (P < 0.05) after 6 +/- 3 weeks. The invasively assessed pressure gradient at rest was reduced from 63.7 +/- 15.2 to 21.2 +/- 11.1 mmHg (P < 0.01) and the post-extrasystolic gradient was reduced from 138.9 +/- 12.7 to 45.6 +/- 16.5 mmHg (P < 0.01). All differences as well as the quantity of injected ethanol were plotted against the size or amount of scar tissue as assessed in the MRI. There was a statistically significant correlation between the post-extrasystolic gradient decrease and the amount of scar tissue (P = 0.03, r (2) = 0.5). In addition, the correlation between the quantity of ethanol and scar tissue area was highly significant (P < 0.01, r (2) = 0.6), whereas the values for the gradient deviation (P = 0.10, r (2) = 0.34), DeltaV (max) (P = 0.12, r (2) = 0.31), as well as the gradient at rest (P = 0.27, r (2) = 0.17) were not significant.

Conclusion: TASH was consistently effective in reducing the gradient in all patients with HOCM. In contrast to the variables investigated by echocardiography, the invasively measured post-extrasystolic gradient correlated much better with the amount of scar tissue as assessed by CMR. We conclude that the optimal modality to visualize the TASH effect seems to be a combination of CMR and the invasive identification of the post-extrasystolic gradient.