Evaluation and Management of Concomitant Hypertrophic Obstructive Cardiomyopathy and Valvular Aortic Stenosis

Abstract

The dilemma of the patient with both AS and LVOTO is now commonly encountered in clinical practice; indeed, physicians must be aware of the complex interaction and coexistent nature of both diseases, especially as both HOCM and TAVR have increased in awareness and prevalence. Importantly, the clinician must be aware of the complex interplay hemodynamically, with the two diseases confusing the TTE imaging and potentially affecting each other anatomically and clinically. There is no set guideline on how to approach this from a surgical or percutaneous approach, but we have outlined a set of recommendations which should serve the clinician and patient well. The three cases that are presented illustrate that methodical diagnosis in addition to the order of treatment do indeed matter. In the first case, there was AS and an underestimated LVOT gradient that was also present. Once the AS was corrected, the true LVOT gradient potential was evidenced and she decompensated, likely because there was a rapid decrease in afterload. Patients with concomitant LVOTO are not able to adjust quickly to the hemodynamic changes created by the rapid decline in afterload, as, for example, in HOCM patients who receive nitroglycerin. The second case demonstrated that when the LVOTO was severe and the AS nonsignificant (mild or moderate), the patient was able to live without symptoms for several years after successful alcohol septal ablation (ASA). She eventually needed an aortic valve and mitral valve replacement but that was postponed for several years until the AS became more significant, and the surgical risk was lowered by the elimination of the need for concomitant myectomy. In the last case, the patient was able to have both an ASA and TAVR within 3 months of each other without hemodynamic compromise. Indeed, this latter therapy sequence may be the best way to treat patients with both diseases in the future, as both ASA and TAVR continue to evolve into intermediate and lower-risk patient populations and the safety of ASA continues to be evident.

Alcohol septal ablation in patients with concomitant hypertrophic cardiomyopathy and aortic valvular stenosis

“…Its utility in patients with serial obstructions related to HCM and AS is unclear. 6 In this case series, we describe the hemodynamic and early clinical outcomes of six patients with echocardiographic and hemodynamic findings suggestive of dynamic LVOT obstruction and fixed AS obstruction. We found that septal ablation in this setting was well tolerated and associated with a significant immediate reduction in the dynamic LVOT gradient with residual fixed gradient associated with AS.…”

“…Alcohol septal ablation is an established treatment modality to relieve dynamic LVOT obstruction in patients with symptoms refractory to medical therapy deemed to be high‐risk for surgery. Its utility in patients with serial obstructions related to HCM and AS is unclear . In this case series, we describe the hemodynamic and early clinical outcomes of six patients with echocardiographic and hemodynamic findings suggestive of dynamic LVOT obstruction and fixed AS obstruction.…”

“…However, observational data describing the hemodynamic and clinical outcomes of TAVR or septal ablation for high‐risk surgical patients in the setting of serial obstructions is lacking. Concerns exist that relieving the predominant obstruction may have the untoward effect of worsening the less significant obstruction . For example, in patients who are thought to have a primarily fixed obstruction related to severe AS, proceeding with TAVR and its associated afterload reduction may lead to a significant increase in the dynamic LVOT obstruction, as seen in Cases 5 and 6.…”

“…Alcohol septal ablation has the potential to improve symptoms in patients who are thought to have a significant contribution from dynamic LVOT obstruction. It has been previously described in patients with coexistent AS both prior to and after TAVR . Despite this, the feasibility, safety, and efficacy of alcohol septal ablation in this setting remains unclear as existing data is limited solely to case reports in the literature.…”

“…It has been previously described in patients with coexistent AS both prior to and after TAVR. [6][7][8][9][10][11] Despite this, the feasibility, safety, and efficacy of alcohol septal ablation in this setting remains unclear as existing data is limited solely to case reports in the literature. In this series, we describe the hemodynamic and early clinical outcomes of percutaneous alcohol septal ablation in six patients with serial left ventricular outflow obstructions due to HCM and AS.…”