HomeCirculationVol. 109, No. 5Avoiding Papillary Muscle Infarction With Myocardial Contrast Echocardiographic Guidance of Nonsurgical Septal Reduction Therapy for Hypertrophic Obstructive Cardiomyopathy Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBAvoiding Papillary Muscle Infarction With Myocardial Contrast Echocardiographic Guidance of Nonsurgical Septal Reduction Therapy for Hypertrophic Obstructive Cardiomyopathy Sherif F. Nagueh, MD, Nasser M. Lakkis, MD, Katherine J. Middleton, RCT, Jennifer Franklin, RN and William H. SpencerIII, MD Sherif F. NaguehSherif F. Nagueh From the Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Tex. Search for more papers by this author , Nasser M. LakkisNasser M. Lakkis From the Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Tex. Search for more papers by this author , Katherine J. MiddletonKatherine J. Middleton From the Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Tex. Search for more papers by this author , Jennifer FranklinJennifer Franklin From the Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Tex. Search for more papers by this author and William H. SpencerIIIWilliam H. SpencerIII From the Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Tex. Search for more papers by this author Originally published10 Feb 2004https://doi.org/10.1161/01.CIR.0000115644.35804.8BCirculation. 2004;109:e27–e28Intracoronary myocardial contrast echocardiography (MCE) can be used to guide the delivery of ethanol during nonsurgical septal reduction therapy for hypertrophic obstructive cardiomyopathy. The echocardiographic contrast agent is injected immediately before the injection of ethanol, down the lumen of the inflated balloon that resides in the target septal coronary artery. This is the artery that supplies the area of the septum involved with the mitral leaflet(s) in causing dynamic outflow tract obstruction. MCE provides a direct visualization of the myocardial territory that should receive ethanol and consequently undergo infarction. In rare instances, the cannulated vessel does not supply the culprit septal segment(s) but supplies instead other myocardial territories. It is important to avoid the injection of ethanol in these instances because infarction of myocardial segments not involved with obstruction will occur, the dynamic gradient will not be relieved, and the patient will be subjected to the detrimental effects of a potentially large myocardial infarction.We present here a case in which the initially cannulated vessel was supplying a papillary muscle, a situation that was readily identified by MCE (Figures 1 through 7). Ethanol injection was aborted, and the balloon was disengaged from the vessel. Subsequently, a smaller, more proximal artery was successfully cannulated, and MCE confirmed its limited distribution to the culprit septal segments with no papillary muscle opacification. After ethanol injection, the dynamic gradient decreased dramatically in the catheterization laboratory. Download figureDownload PowerPointFigure 1. Cine 1; apical 4-chamber view showing flow acceleration by color Doppler echocardiography across the left ventricular outflow tract due to dynamic outflow tract obstruction.Download figureDownload PowerPointFigure 2. Cine 2; apical 4-chamber view (showing the septum and lateral walls) after the intracoronary injection of Optison (echocardiographic contrast agent) down the lumen of the inflated balloon engaged in the initially cannulated septal coronary artery. Notice the opacification of the basal septum only in this view (lateral wall not opacified).Download figureDownload PowerPointFigure 3. Cine 3; apical 2-chamber view (showing the anterior and inferior walls) showing Optison opacifying the basal area of the posterior papillary muscle.Download figureDownload PowerPointFigure 4. Still frame from an apical off-axis view showing the opacification of the whole papillary muscle. This resulted in aborting the plan to inject ethanol down this artery to avoid inducing papillary muscle infarction.Download figureDownload PowerPointFigure 5. Cine 4; after another proximal septal perforator was cannulated, this apical 4-chamber view was acquired. Notice opacification by MCE of only the basal septum.Download figureDownload PowerPointFigure 6. Cine 5; noticeable in this apical 2-chamber view is a lack of any opacification of the papillary muscle that was initially noted. Accordingly, ethanol was injected down the lumen of this artery.Download figureDownload PowerPointFigure 7. After injection of ethanol, the dynamic outflow tract gradient decreased from 93 to 16 mm Hg.Movies are available in the online-only Data Supplement at http://www.circulationaha.org.The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD. Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St. Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.FootnotesCorrespondence and reprint requests to Sherif F. Nagueh, MD, Section of Cardiology, 6550 Fannin St, SM-1246, Houston, TX 77030-2717. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetailsCited By Xu S, Ilyas I, Little P, Li H, Kamato D, Zheng X, Luo S, Li Z, Liu P, Han J, Harding I, Ebong E, Cameron S, Stewart A, Weng J and Ma Q (2021) Endothelial Dysfunction in Atherosclerotic Cardiovascular Diseases and Beyond: From Mechanism to Pharmacotherapies, Pharmacological Reviews, 10.1124/pharmrev.120.000096, 73:3, (924-967), Online publication date: 1-Jul-2021. 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