Percutaneous Septal Myocardial Ablation

(PASMA)

Cardiovascular Institute & Fu Wai Hospital

Chinese Academy of Medical Science

You Shi Jie MD2010.7. 23 GuiYang2010.7. 23 GuiYang

经皮间隔支化学消融治疗肥厚梗阻性心肌病

IntroductionIntroduction Treatment of symptomatic patients with HOCM aims to Treatment of symptomatic patients with HOCM aims to

reduce symptoms, improve function capacity and provide reduce symptoms, improve function capacity and provide better quality life.better quality life.

Aims directly to reduce the hypertrophied interventricular Aims directly to reduce the hypertrophied interventricular septum with consecutive expansion of the LV outflow tract septum with consecutive expansion of the LV outflow tract and reduction of the LV outflow tract gradient and and reduction of the LV outflow tract gradient and improve distolic function LV.improve distolic function LV.

First choice druges treatmentFirst choice druges treatment.. At leastAt least 10%10% of of patients with marked outflow tract obstruction have severe patients with marked outflow tract obstruction have severe symptoms, which are unresponsive to medical therapy.symptoms, which are unresponsive to medical therapy.

HOCM MyectomyHOCM Myectomy DDD-PMDDD-PM ICDICD PTSMA PTSMA

Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy Epidemiological characteristicsEpidemiological characteristics Hypertrophic cardiomyopathy incidence of Hypertrophic cardiomyopathy incidence of

0.2%0.2% (1:500), (1:500), 0.16%0.16% in our country in our country . . The vast majority of patients with no symptoms,The vast majority of patients with no symptoms, 25%25% of outflow tract obstruction occurred of outflow tract obstruction occurred only about only about 5-10%5-10% of patients with drug of patients with drug

treatments fail or cause serious side effects of treatments fail or cause serious side effects of drugs effective dose.drugs effective dose.

Require treatment or surgical intervention in Require treatment or surgical intervention in patients treated with only very few parts.patients treated with only very few parts.

Pathophysiologic and clinical Pathophysiologic and clinical characteristics of HOCMcharacteristics of HOCM

Ventricular hypertrophyVentricular hypertrophy Left ventricular outflow tract pressure gradient Left ventricular outflow tract pressure gradient Myocardial ischemia-angina pectoris. Myocardial ischemia-angina pectoris. Arrhythmia - Arrhythmia - ventricular tachycardia, fibrillation . . Clinical manifestations: dizziness, amaurosis, Clinical manifestations: dizziness, amaurosis,

syncope, exertional shortness of breath, angina syncope, exertional shortness of breath, angina pectoris, heart disfunction and sudden death. pectoris, heart disfunction and sudden death.

Generally considered: more severe hypertrophy, Generally considered: more severe hypertrophy, outflow tract obstruction near the LVOT sit, the outflow tract obstruction near the LVOT sit, the more higher the obstructive pressure gradient were more higher the obstructive pressure gradient were the more obvious clinical symptoms and the greater the more obvious clinical symptoms and the greater the potential threat.the potential threat.

The natural course of outflow The natural course of outflow tract obstructiontract obstruction

Level –any ages. there is a big difference in Natural history The natural course The natural course not sure. The more cardiac hypertrophy, the higher the

pressure gradient, the greater the risk of sudden death.

 The outflow tract pressure gradient of the clinical importance of the issue remains controversial, but it is generally considered an important clinical process indicators.

Nnual mortality rate of 2-4%, the incidence of sudden death ≤1%

The symptomsThe symptoms

Whether the obstruction produced the clinical symptoms? not only with the degree of outflow tract obstruction and outflow tract pressure gradient, as well as the obstruction site. But also with ventricular diastolic function and the adequacy of venous return is also closely related. Increase the heart before and after load and myocardial contractility often cause noticeable clinical symptoms. Therefore, it will become more apparent after exercise . The patients should be treatment.

Diastolic dysfunctionDiastolic dysfunction♦ All patients had diastolic dysfunction – ♦ How the pressure gradient and symptoms♦ And the extent and distribution of the

hypertrophy has nothing to do. ♦ Whether normal or small ventricular cavity, due

to increased heart weight, ventricular volume reduction, myocardial fibrosis, leaving ventricular stiffness increased, compliance decreased and caused the diastolic function damage. Pulmonary venous pressure and end-diastolic pressure were increased and heart disfunction.

systolic function Systolic function is normal or supranormal in HCOMSystolic function is normal or supranormal in HCOM Both obstruction and non-obstruction, Systolic dysfunction Both obstruction and non-obstruction, Systolic dysfunction

occurs in small subset occurs in small subset (10-15%)(10-15%) Result of progressive impairment of systolic function.Result of progressive impairment of systolic function. This transformation: wall thinning, cavity dilation, and This transformation: wall thinning, cavity dilation, and

fibrosis, increased mortality fibrosis, increased mortality 11%11% (annual ) and risk of (annual ) and risk of SCD. SCD.

Conventional UCG, M-mode, or EF, fractional shortening Conventional UCG, M-mode, or EF, fractional shortening preserved despite impaiment long-axis functionpreserved despite impaiment long-axis function

Tissue Doppler image (TD)-derived systolic velocities: in Tissue Doppler image (TD)-derived systolic velocities: in the basal inferoseptal and anterolateral wall routinely in the basal inferoseptal and anterolateral wall routinely in all patients on subsequent scans.all patients on subsequent scans.

Myocardial ischemia• Myocardial ischemia, the symptoms of angina

pectoris are: • High-power so that left ventricular myocardial

oxygen consumption increased; • Cardiac contraction strength of oppression the

large myocardial coronary artery; • Intramyocardial small coronary artery stenosis

and intimal thickening abnormalities, leading to cardiac hypertrophy and coronary artery oxygen required due to an imbalance of oxygen supply.

Arrhythmia and Arrhythmia and sudden death

HOCM of patients with abnormal myocardial cells and the arrangement of disorder provides a basis for the arrhythmia.

However, abnormal myocardial arrangement and spontaneous arrhythmias and ventricular fibrillation threshold, the precise relationship is unclear.

About 25% of patients may have non-sustained ventricular tachycardia, the arrhythmia is sudden death of a good predictor, and negative predictive accuracy is 97%.

Risk factors for sudden Risk factors for sudden death death

• High-risk:High-risk: 1 Sudden death occurred in a successful 1 Sudden death occurred in a successful

rescuerescue            2 continuous monomorphic ventricular             2 continuous monomorphic ventricular tachycardiatachycardiaClinical risk factors:Clinical risk factors:            1 non-sustained ventricular tachycardia            1 non-sustained ventricular tachycardia            2 movement abnormal blood pressure             2 movement abnormal blood pressure response ( response ( ≥≥ 25mmHg) 25mmHg)            3 unexplained syncope            3 unexplained syncope            4 early-onset family history of sudden death            4 early-onset family history of sudden death            5 severe left ventricular hypertrophy> 30mm            5 severe left ventricular hypertrophy> 30mm

The purpose of the treatment PTMSA

Treatment of symptomatic patients with Treatment of symptomatic patients with HOCM HOCM The PTMSA treatment of HOCM is a obstruction

by blocking a the supply blood of parts of the septal hypertrophy of myocardial and myocardial injury in the region, leading to the area of myocardial necrosis, myocardial contractile function disappeared, Widened the left ventricular outflow tract, while lowering the outflow tract obstruction and the cardiac output increase. And improve clinical symptoms and hemodynamics.

PTSMA PTSMA indication indication (1) (1)

Clinical indicationClinical indicationSymptomatic patientsSymptomatic patients Drug refractory severe said effects medical Drug refractory severe said effects medical

treatmenttreatment Functional class III or IVFunctional class III or IV Functional class II with objective limitation or Functional class II with objective limitation or

risk factorsrisk factors Recurrent exercise-induced syncopesRecurrent exercise-induced syncopes Failure of prior myectomy or DDD-PMFailure of prior myectomy or DDD-PM Comorbitiy with increased surgical risk.Comorbitiy with increased surgical risk.

PTSMA PTSMA indication indication (2) (2)Hemodynamic indication in symptomatic patientsHemodynamic indication in symptomatic patients The pressure gradient at rest > 50mmHg or > 100mmHg

with provocation. In 2008 ESC meeting, Seggewise that LV gradient LV gradient 30≧30≧

mmHg at rest or Provocable LV gradient mmHg at rest or Provocable LV gradient 60≧ 60≧ mmHg. mmHg. ValsalvaValsalva Post extrasystole.Post extrasystole. No dobutamine gradients (Drugs)No dobutamine gradients (Drugs)

((There is no information that reduce the LVOT There is no information that reduce the LVOT pressure to reduce sudden death, but the LVOT> pressure to reduce sudden death, but the LVOT> 30mmHg and increased risk of death directly 30mmHg and increased risk of death directly related to, related to, New Eng l J Med 2003; 348:295-303)New Eng l J Med 2003; 348:295-303)

Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy Survival According to Outflow Tract Survival According to Outflow Tract

GradientGradient

BJ Maron et al; JAMA 281:650-655, 1999

PTSMA PTSMA indication indication (3)(3)

Morophologic indicationMorophologic indicationEchocariographyEchocariography Subaorrtic SAM-associated gradient Subaorrtic SAM-associated gradient Mid-cavitary gradient Mid-cavitary gradient Caution: papillary muscle involvement: Caution: papillary muscle involvement: MCEMCE No prolonged mitral leaflets No prolonged mitral leaflets Coronary angiographyCoronary angiography suitable septal branch.suitable septal branch.

Outflow tract obstruction sign in Echocardiograph

• M-mode echocardiogram in obstructive hypertrophic cardiomyopathy showing systolic anterior motion of the mitral valve (SAM) (arrows indicating septum and mitral valve leaflet contact)

MorphologicMorphologic of HOCM of HOCMNew classfication of HOCM New classfication of HOCM

Methods: they were classified into Methods: they were classified into 4 types according to the 4 types according to the echocardiographic results:echocardiographic results:

Type IType I :local subaortic obstruction :local subaortic obstruction of HOCM;of HOCM;

Type IIType II: predominant in : predominant in midventicular obstruction;midventicular obstruction;

Type IIIType III: diffuse septal : diffuse septal hypertrophic obstruction in hypertrophic obstruction in outflow tract and midventicular outflow tract and midventicular obstruction;obstruction;

Type IVType IV: multiposition hypertrophic : multiposition hypertrophic obtruction.obtruction.

1.asymmetrical septal hypertrophy 1.asymmetrical septal hypertrophy (ASH),(ASH), 2.Idiopathic 2.Idiopathic hypertrophic subaortic stenosis hypertrophic subaortic stenosis (IHSS),(IHSS), 3.Apical or 3.Apical or Japanese HCMJapanese HCM. In this form of nonobstructive HCM, . In this form of nonobstructive HCM, the thickest part of the left ventricle is at the tip or apex the thickest part of the left ventricle is at the tip or apex of the pump .4. the obstruction is not in the outflow of the pump .4. the obstruction is not in the outflow tract but in the middle of the ventricle. A tunnel leads tract but in the middle of the ventricle. A tunnel leads into a dilated apical portion, called an aneurysm, which into a dilated apical portion, called an aneurysm, which has thin walls. has thin walls.

Our classfication in PTSMA

Our typing in the I-type and MaronMaron in the I-typing was the same as suitable for PTSMA treatment and Maron's II-type includes the type II and type III of our model, it is suitable PTSMA treatment. Therefore, our IV-type classification is the first made by ultrasound imaging features of HOCM, according to its characteristics in line with PTSMA treatment.

TargetTarget vesselvessel Select ablation of regional importance, Select ablation of regional importance,

particularly in the target vessel is not clear who particularly in the target vessel is not clear who the septal branchthe septal branch     The first septal branch of the size and      The first septal branch of the size and distribution are great variationdistribution are great variation

20%20% of patients first branch was supplied the free of patients first branch was supplied the free wall of right ventricle wall of right ventricle

40%40% of patients with of patients with subaortic of septal is not of septal is not completely supported by the first septal branch completely supported by the first septal branch

5%5% of patients can not determine the target vessel of patients can not determine the target vessel of the regionof the region

Contrast echocardiography Contrast echocardiography methodmethod

in the target vesse in the target vesse choicechoice1. Injection of a small amount of dye (1-2ml)

through the guidewire lumen of the inflated balloon catheter angiographically

2. Prior to alcohol injection 1-2ml of echo contrast medium is administered through the central lumen of the balloon catheter under UCG. determines the supply area of the target septal branch. Ensure that no areas involving non-obstructive, such as the papillary muscles and ventricular free wall and other parts.

Myocardial - Contrast - EchoMyocardial - Contrast - Echo in in HOCMHOCM

Avoid LAD ballooning

Exclude LAD leakage

Septal Ablation in HOCMSeptal Ablation in HOCMMyocardial - Contrast - EchoMyocardial - Contrast - Echo

Levovist

In the interval of contrast agent injected into the branch to observe the distribution of vascular contr

Alcohol Shadow

Levovist shadow

Echo sequence: Subaortic septum Echo sequence: Subaortic septum as targetbregion in typical SAM-as targetbregion in typical SAM-associated, subaortic obstraction, associated, subaortic obstraction, ( D dotted line) , ( D dotted line) ,

E test injection of the echo contrast E test injection of the echo contrast agent in balloon of the the first setal agent in balloon of the the first setal branch of a forward branch of branch of a forward branch of position highlighting be basal half position highlighting be basal half of septum plus a RV papillary of septum plus a RV papillary muscle (white arrows) . muscle (white arrows) .

After super-After super-selective balloon of selective balloon of other branch of other branch of first septal branch. first septal branch. Correct Correct opacification.opacification.

MCE

N=222

No MCE

n=30P

Septal branches (n) 1.0±0.1 1.3±0.2 <0.0001

Alcohol (ml) 2.9±0.9 3.9±2.4 <0.0001

Balloon size (mm) 1.9±0.4 2.4±0.2 <0.0001

CK max (U/l) 534±248 745±420 <0.001

CK-MB max (U/l) 62±30 96±62 <0.0001

H. Seggewiss et al, 49th Scientific Sessions ACC, 2000H. Seggewiss et al, 49th Scientific Sessions ACC, 2000

Septal Ablation in HOCMSeptal Ablation in HOCMAcute Results / Ablation TechniqueAcute Results / Ablation Technique

86

18

5

70

45

17

0

20

40

60

80

LVOTG-Reducti on>50%

AVB I I I ° 15 Mi n.after PTSMA

DDD-PM

Pat

ient

s (%

)

MCE, n=222 No MCE, n=30

H. Seggewiss et al, 49th Scientific Sessions ACC, 2000H. Seggewiss et al, 49th Scientific Sessions ACC, 2000

Septal Ablation in HOCMSeptal Ablation in HOCMAcute Results / Ablation TechniqueAcute Results / Ablation Technique

p<0.05

p<0.01

keys of Technologykeys of Technology of PTSMAPTSMA

The key technology:The key technology: identification identification The pressure gradient at subaortic and left at subaortic and left

ventricularventricular identification suitable of target septal branches.identification suitable of target septal branches. Must be inserted temporary pacemaker (to prevent the Must be inserted temporary pacemaker (to prevent the

conduction block).conduction block).   Simultaneous monitoring of aortic and left ventricular Simultaneous monitoring of aortic and left ventricular

pressure.pressure.     Heparin ( to prevent catheter induced thrombosis). Heparin ( to prevent catheter induced thrombosis).   AnalgesicAnalgesic Guiding catheter: supporting flexible and low injury Suitable Over-the-wire balloon catheter

The keys of TechnologyThe keys of Technology PTSMAPTSMA

Intraoperative ultrasound monitoring Contrast echocardigraphy Pay close attention to the pressure gaugePay close attention to the pressure gauge under fluoroscopy (observation balloon expansion of under fluoroscopy (observation balloon expansion of

state).state). Injection of alcohol dose and speedInjection of alcohol dose and speed

determine whether should injury (catheter or alcohol) and determine whether should injury (catheter or alcohol) and

the interval branch block (necrosis state) conditionsthe interval branch block (necrosis state) conditions 1 (with complications) or 2 septal branches ablation did

not significantly reduce the pressure, and no increase alcohol dose

Remove balloon should be emptying alcohol of the balloon catheter and stagnation injection alcohol

A 51-year-old woman’s LVOT A 51-year-old woman’s LVOT gradient was monitored gradient was monitored continuously just before the continuously just before the balloon occlusion . balloon occlusion . (PG=80mmHg)(PG=80mmHg)

LV

AO

Her LVOT gradient 10 Her LVOT gradient 10 minutes after septal minutes after septal

ablation ablation （（ PG=12mmHgPG=12mmHg））

LVAO

A 36-year-old man’s LVOT A 36-year-old man’s LVOT gradient tested by gradient tested by Doppler echocardiography Doppler echocardiography before PTSMA before PTSMA (PG=219mmHg)(PG=219mmHg)

His LVOT gradient 6 months after PTSMA (PG=15mmHg)

PG120mmHg before PG120mmHg before procedureprocedure

PG=40mmHg after injection PG=40mmHg after injection of 4.8 ml alchoholof 4.8 ml alchohol

Great attention Great attention Echocardiography showed ventricular

septal hypertrophy over 30 mm in HOCM, necessary to performeing PTSMA should be very cautious and careful. May be there were a thick septal branch, and control wide, and collateral-rich septal branch of support, treatment had a higher risk and improve the clinical symptoms and hemodynamics have difficulties, so surgery mytomce may be a better choice.

It is very big septal branch > 2.5mm and too long. It is very big septal branch > 2.5mm and too long. There is quite danger to PTMSAThere is quite danger to PTMSA

PTSMA contraindicationsPTSMA contraindications No significant pressure gradient in hypertrophic No significant pressure gradient in hypertrophic

cardiomyopathy or very diffuse obstructive.cardiomyopathy or very diffuse obstructive. Merge other needs surgery heart diseaseMerge other needs surgery heart disease

    Mitral valve abnormalities and their own form     Mitral valve abnormalities and their own form of papillary muscles involved in the formation of of papillary muscles involved in the formation of pressure gradient, or mitral valve prolapse and pressure gradient, or mitral valve prolapse and regurgitation.regurgitation.

Contrast echocardiography can not determine can not determine target vessel or the obstruction of regional no target vessel or the obstruction of regional no suitable target vessel.suitable target vessel.

Target vessel supply to non-obstruction other Target vessel supply to non-obstruction other regions such as: papillary muscle, free wall, etc.regions such as: papillary muscle, free wall, etc.

Not suitableNot suitable Over-the-wire balloon.

PTSMA complications (1)PTSMA complications (1) Hospital mortality rate Hospital mortality rate :1-2%:1-2% DDD-pacemaker :DDD-pacemaker :2-10%2-10%   Myocardial infarctionMyocardial infarction

Reason:Reason: alcohol alcohol leakageleakage into the parts of into the parts of inappropriate, inappropriate, collateralcollateral branch opening , alcohol branch opening , alcohol into the inappropriate parts cause no-reflow, LAD into the inappropriate parts cause no-reflow, LAD / LM / RCA injury/ LM / RCA injury

  Emergency surgeryEmergency surgery Reason: Reason: coronary artery injury, acute mitral coronary artery injury, acute mitral regurgitation (papillary muscle rupture )regurgitation (papillary muscle rupture )

Bundle branch block: about Bundle branch block: about 50%50% and RBBB- and RBBB-basedbased

PTSMA complications (2)PTSMA complications (2) Height or III °-AVBHeight or III °-AVB

  Factors:Factors: whether whether the method of application of the method of application of myocardial contrast echocardiography. myocardial contrast echocardiography.

DoseDose of alcohol and of alcohol and speedspeed.. Left anterior descending artery dissection, Left anterior descending artery dissection,

coronary thrombosis, ventricular fibrillation and coronary thrombosis, ventricular fibrillation and ventricular tachycardia, acute mitral ventricular tachycardia, acute mitral regurgitation, right ventricular infarction, left regurgitation, right ventricular infarction, left ventricular free wall infarction.ventricular free wall infarction.

PTSMA shortcomingsPTSMA shortcomings Injury of the left coronary artery required Injury of the left coronary artery required

emergency bypass or stentemergency bypass or stent   Can not enter the target septal branch Can not enter the target septal branch  Can not determine the target branch of supportCan not determine the target branch of support For mitral and papillary muscle anomalies and For mitral and papillary muscle anomalies and

abnormal septal hypertrophy the best choice the abnormal septal hypertrophy the best choice the surgerysurgery

  Mitral valve injury required emergency surgery .Mitral valve injury required emergency surgery .   Permanent conduction block occurs treatment Permanent conduction block occurs treatment

should be PMshould be PM

PTSMA limitationsPTSMA limitations Some young patients to reduce the Some young patients to reduce the

pressure gradient effect is not satisfactory, pressure gradient effect is not satisfactory, the possible reasons:the possible reasons:

The septal branch with good collateral The septal branch with good collateral circulation.circulation.

The vessel can not thoroughThe vessel can not thorough or incomplete or incomplete ablation (remaining smaller branches), self-ablation (remaining smaller branches), self-revascularization.revascularization.

A higher degree of septal hypertrophy, a A higher degree of septal hypertrophy, a higher degree of fibrosis, Parts of the septal higher degree of fibrosis, Parts of the septal ablation scar formation poor.ablation scar formation poor.

PTSMA in PTSMA in Fuwai HospitalFuwai Hospital

• From Dec 2000 to May 2009 , 171 From Dec 2000 to May 2009 , 171 patients underwent PTSMA in patients underwent PTSMA in Fuwai Hospital.Fuwai Hospital.

• Procedure success was achieved in Procedure success was achieved in 141 patients141 patients ，， success rate was success rate was 82.6%. 82.6%.

Patient CharacteristicsCharacteristics Patients (n=171)

Age (yrs) 45.37±17.71

Men/women 122/49 (71.35%/28.65%)

Symptoms

Dyspnea 93 (54.39%)

Angina 73 (42.69%)

Syncope 76 (44.44%)

NYHA functional class （ II/III/IV ）

136(79.53%) /32(18.72%)/ 3(1.75%)

Family history 42 (24.6%)

Medication

Beta-blockers 106 (62%)

Verapamil 52 (30.4%)

Diltiazem 38 (22.2%)

Amiodanone 13 (7.6%)

Results of PTSMAResults of PTSMAPTSMA (n=171) p

Septal thickness

(pre-PTSMA)

22.67±5.35mm

Septal thickness

(post-PTSMA 3days)

20.68±4.61mm NS

Septal thickness

(post-PTSMA 6months)

16.77±4.39mm <0.05

LVOTPG

(pre-PTSMA)

97.58±38.23mmHg

LVOTPG

(post-PTSMA 3days)

52.36±35.7mmHg <0.001

LVOTPG

(post-PTSMA 6months)

47.26±38.62mmHg <0.001

LA Diameter

(pre-PTSMA)

43.78±7.33mm

LA Diameter

(post-PTSMA 3days)

42.41±7.52mm NS

LA Diameter

(post-PTSMA 6months)

32.76±15.58mm <0.05

Complications in our Complications in our patientspatients

In-hospital deathIn-hospital death • Up to May 2009 , two patients died in those 171 Up to May 2009 , two patients died in those 171

patientspatients （（ 1.17%1.17% ） ） who underwent PTSMA in who underwent PTSMA in Fuwai Hospital. One was because of alcohol Fuwai Hospital. One was because of alcohol leakage to the Left anterior decending artery, leakage to the Left anterior decending artery, another occurred drug-induced liver injury .another occurred drug-induced liver injury .

Complete heart block Complete heart block • Transitory trifascicular blocks occurred at a rate Transitory trifascicular blocks occurred at a rate

of of 52.05%52.05% （（ 89 patients).89 patients). • Only one patient Only one patient (0.59%)(0.59%) underwent permanent underwent permanent

pacemaker implantation due to permanent pacemaker implantation due to permanent complete AV block.complete AV block.

Complications in our Complications in our patientspatients

• One patientOne patient (0.59%) (0.59%) occurred ventricular occurred ventricular fibrillation , but he recovered well after the fibrillation , but he recovered well after the procedure.procedure.

• Right bundle branch block occurred at a Right bundle branch block occurred at a rate of rate of 48.54%48.54% （（ 83 in 171 patients).83 in 171 patients).

• No dissections of the LM and LAD .No dissections of the LM and LAD .

• No emergency CABGNo emergency CABG

• Acute mitral regurgitation also did not Acute mitral regurgitation also did not occur.occur.

Follow-up in our patients Follow-up in our patients by echo by echo

  Left ventricular outflow tract pressure gradient was Left ventricular outflow tract pressure gradient was continued to a significant decrease is an important continued to a significant decrease is an important feature: feature:

Compared with the acute phase, Compared with the acute phase, 56%56% of patients 3 of patients 3 months resting and stimulate the pressure gradient will months resting and stimulate the pressure gradient will continue to decline further; Compared with 3-month continue to decline further; Compared with 3-month period, period, 43 %43 % of patients one year the pressure gradient is of patients one year the pressure gradient is still further reduced. still further reduced.

After  3 months After  3 months 40%40% of patients with pressure gradient of patients with pressure gradient completely reduced, a year later this value was promoted completely reduced, a year later this value was promoted to to 62%62% . .

43 months later, 43 months later, 90%90% of the patients of the pressure of the patients of the pressure gradient completely eliminated by echocardiographicgradient completely eliminated by echocardiographic

CONCLUSIONSCONCLUSIONS♦ PTSMA is an effective non-surgical procedure PTSMA is an effective non-surgical procedure

for symptomatic patients and associated with for symptomatic patients and associated with LVOTO in HOCM because of its LVOTO in HOCM because of its low risklow risk and its and its significantsignificant hemodynamic and symptomatic hemodynamic and symptomatic improvement. improvement.

♦ Ablation area should be appropriate, as small as possible, to avoid a large scar formation.

♦ Echocardiographic observations plays an Echocardiographic observations plays an important role in that will help to finalize define important role in that will help to finalize define the choice of septal ablation and the ablation the choice of septal ablation and the ablation efficacy and reduce risks and Long-term follow-efficacy and reduce risks and Long-term follow-up of treatment efficacyup of treatment efficacy ..

Advice

Who have no symptoms or mild Who have no symptoms or mild symptoms of the patient, determined symptoms of the patient, determined not to consider the line to reduce not to consider the line to reduce outflow tract obstruction of any outflow tract obstruction of any therapeutic intervention measurestherapeutic intervention measures (including surgical and interventional (including surgical and interventional treatment)!!!treatment)!!!