Posted on Authorea 8 Oct 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.160218234.40856888/v1 — This a preprint and has not been peer reviewed. Data may be preliminary. hr a loeeainadedeulzto fdatlcpesrsi l orcriccabr o2 mmHg, 25 to chambers cardiac four all in pressures ( ( diastolic PVC of Extensive inspiration end-equalization a during and after elevation decreased mmHg. also response gradient was 31 There Brockenborough The midventricular combined of a obstruction. from ( with gradient angiography outflow ) and CT ventricular with apex on left LV obstruction seen the of subaortic were midventricular between gradient arch and gradient aortic addition, Doppler large and a peak in aorta demonstrated a ascending catheterization was, the with There in obstruction plaques (LVOT) calcified tract mitral outflow mmHg. the ventricular of 77 left motion squat anterior severe the systolic from producing and increased valve hypertrophy which and septal border demonstrated X sternal left rapid Transthoracic the with at elevated systemic murmur markedly severe ejection was position. systolic had pressure 2/6 stand venous She a to jugular had Her examination. She mmHg. clinical descents. 180/90 Y her of on and pressure findings blood breath with important of several shortness were exertional of There Post symptoms limiting pacemaker-defibrillator. persistent were transvenous compli- fullness. experience dual-chamber block that chest a to symptoms Complete received continued progressive she she institution. of and another Because procedure, course, at ASA post-ablation underwent years. her she three cated therapy, complaints with for medical Clinic with fullness our relieved chest to not presented and HCM breathlessness obstructive of exertional diagnosis of previous the with had woman 71-year-old patient A the that cardiac management potential report and multiple present presentation have to Patient the found in was and disability. describe ASA her we following alcohol for months obstruction.[1,2] patient, or causes six tract myectomy the for outflow ventricular dyspnea septal from left exertional recurrent surgical consent persistent or by residual written reduction to obtaining due septal often After after most is early (ASA) symptoms ablation septal of recurrence or Persistence aorta. Introduction , ascending complete calcified underwent heavily She a of atherosclerosis. replacement aortic and by myectomy, constric- for reflected transapical volume, causes myectomy, as potential end-diastolic septal stiffness, four reducing transaortic have arterial hypertrophy ventricular to marked found of left and was distribution She of pericarditis, alcohol apical tive symptoms. prior relief obstruction, her and midventricular inadequate causing (HCM) residual findings to cardiomyopathy of symptoms, related constellation hypertrophic her unique with often a woman had most 71-year-old who are ablation a septal therapy encountered recently reduction We septal gradients. after outflow symptoms recurrent or Residual Abstract 2020 8, October 1 Ghoniem Khaled Cardiomyopathy Hypertrophic Obstructive Alcohol For Following Ablation Dyspnea Septal Persistent of Presentation Unusual An aoClinic Mayo 1 ikNishimura Rick , 1 n atelSchaff Hartzell and , iue2B Figure 1 ,idctn yai uflwobstruction. outflow dynamic a indicating ), 1 iue1 Figure iue2A Figure .Cardiac ). Posted on Authorea 8 Oct 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.160218234.40856888/v1 — This a preprint and has not been peer reviewed. Data may be preliminary. 1 h H unaaE ca V ihmr A ern A blM,e l eiuladrecurrent and Residual al. et MD, Abel JA, outcomes and Dearani replacement obstruction RA, of cardiomyopathy—mechanisms graft Nishimura hypertrophic HV, and for myectomy Schaff septal aorta E, after gradients ascending hemostasis. Quintana ensuring YH, the for Cho of and [1] area excision subaortic case, the present and exposing for ascending the References: the method In safest in the present is be aorta. to plaque clamping reflect the aortic extensive appeared may in of when and difficulty aortotomy potential portions elderly the simple the is sinus following surgeon in the hemostasis prevalent to securing is importance aorta,” and more Of ”porcelain stiffness.[6]. aorta, arterial proceeding ascending increased hemo- the supported Detailed of finding calcification important Extensive this diagnosis. the and regarding [5] pericarditis our suspicion constrictive operation. in dis- raised events with suggest antecedent to and no did difficult were constriction assessment There be caused HCM, may dynamic have and it CP might between and that fatigue [4] and patient filling, dyspnea septal ventricular of symptoms diastolic ventricular the impaired mid tinguish with causes myectomy.[3] for patients (CP) in subaortic approach in Combined pericarditis the injection myectomy Constrictive transapical for require surgical prefer SRT. exposure For may transaortic we before and with obstruction, this alcohol. combined ASA midventricular of identify resection with volume and to eliminate excess subaortic important with to indistinguishable both is arteries difficult often perforating it is are septal and obstruction multiple that obstruction, midventricular symptoms Patients pa- subaortic and our effort-related by subaortic in procedure. have caused illustrated post obstruction As outcome those functional midventricular from myectomy. poor and surgical to HCM contribute to may compared therapy with problems reduction ASA cardiac septal following other following common however, symptoms more tient, persistent be of may cause and common (SRT) a is the dismissed obstruction postoperatively subaortic was years Residual She three follow-up there last of and obstruction. symptoms. time 67% subaortic cardiac the Comment was At of residual free fraction or and operation. ejection valve well after ventricular mitral was days left patient 7 the hospital TTE, of infil- the postoperative motion lymphoplasmacytic from non-granulomatous home anterior On pathology and systolic Postoperative cm) no mmHg. 1 . was 14 to the of (up anterior of gradient thickening systolic intraventricular tration fibrous maximum residual non-calcified a no and a with valve myectomy confirmed we mitral from ventriculotomy, the result apical of trans- an good intraoperative motion through a and strip and demonstrated bypass, felt wound, echocardiography cardiopulmonary with ends the following closed esophageal distal was satisfactory into ventriculotomy and was elevated 22-mm apical proximal Hemodynamics was The A the heart myectomy. reinforcement. myectomy. to septal the midventricular sewed septal of extensive and transaortic an apex of length performed extended The correct midportion an aorta. the calcified performed the to the trimmed of then right and was We the cross-clamped, graft anterior in was replacement excised. the Hemashield aorta placed was including was The performed aorta a was cannula ascending following pericardiectomy pericardium. two-stage the complete Hg diaphragmatic a a the mm bypass, inflow, and of 143 mm arterial phase portion 20 to for initial and the increased arch During rest this aortic at . proximal and Hg the rest, mm cannulating at 7 After was Hg gradient gradient mm the the 80 myectomy, PVC. bypass, After was following to aorta Hg Prior calcifi- (PVC). myectomy. severe the contraction Further, for to ventricular aortotomy premature adequate constrictive. left intensely an prevented and the thickened aorta from be proximal to the found of was cation pericardium the operation, At (BMI disease. obesity pericarditis pulmonary obstructive diabetes, constrictive chronic of hypertension, diagnosis systemic 2.3L/min/M the included to with reduced consistent was all index cardiac the and 2 h a vdneo nacdvnrclrinteraction ventricular enhanced of evidence had she ; 2 > 7gm) aoymlara bilto,and fibrillation, atrial paroxysmal 37kg/m2), Fgr 2C) (Figure diinlmdclproblems medical Additional . Posted on Authorea 8 Oct 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.160218234.40856888/v1 — This a preprint and has not been peer reviewed. Data may be preliminary. hypertrophic-cardiomyopathy presentation-of-persistent-dyspnea-following-alcohol-septal-ablation-for-obstructive- 2.pdf Figure file Hosted hypertrophic-cardiomyopathy presentation-of-persistent-dyspnea-following-alcohol-septal-ablation-for-obstructive- 1.pdf line). Figure (green (gray pressure pressure ventricular aortic right AP: RVP: file line); line); Hosted (red (blue pressure pressure atrial ventricular left left LAP: LVP: line); line); (white electrocardiogram ventricularECG: pericarditis. left in constrictive decrease suggesting simultaneous a inspiration and during pressure ventricular pressure right in increase contraction. an with ventricular (interdependence) premature a following gradient obstruction. midventricular fixed 2 Figure aorta. descending and 1 Is Figure Calcification Aortic Increased al. et Figures: 2017;69:102– T, Hypertension Hisamatsu Men. A, Middle-Aged Vishnu Multiethnic J, in 8. Progression Choo Stiffness B, Arterial Willcox dy- With A, of Associated Fujiyoshi Value pericarditis. J, constrictive al. of Guo et diagnosis [6] Jr, the DR for Holmes pressures ventricular GK, right Danielson 1996;93:2007–13. and CP, Circulation left Appleton in ST, changes Higano Cardiol respiratory RA, Rev namic Nishimura Nat DG, failure. Hurrell heart [5] diastolic curable pericarditis—a Constrictive JK. to approach Oh Transapical 2014;11:530–44. HV, Schaff al. FF, et 2013;96:564–70. Syed Surg JA, Thorac [4] Dearani Ann P, cardiomyopathy. Sorajja hypertrophic MD, in Abel obstruction versus midventricular RA, myectomy for Nishimura myectomy HV, Surgical Schaff al. MR, J Kunkala et cohort. [3] JA, score–matched Dearani propensity A JB, 2019;157:306–15.e3. Geske cardiomyopathy: Surg Cardiovasc hypertrophic RA, obstructive Thorac Nishimura for D, ablation Hang septal HV, alcohol Schaff A, Nguyen 2014;148:909–16. [2] Surg Cardiovasc Thorac J reoperation. of roeaieC niga 3 iw eosrtn utpeclie lqe nteascending the in plaques calcified multiple demonstrating view) (3D angiogram CT Preoperative . roeaiehmdnmcsuywt rcnso h electrocardiogram. the of tracings with study hemodynamic Preoperative . vial at available at available https://authorea.com/users/365240/articles/485424-an-unusual- https://authorea.com/users/365240/articles/485424-an-unusual- ae B Panel hw yai uari btuto ihamre nraein increase marked a with obstruction subaortic dynamic shows 3 ae C Panel h rosso etiua discordance ventricular show arrows the ae A Panel shows