Apical Hypertrophic Cardiomyopathy: Preliminary Attempt at Palliation with Use of Subselective Alcohol Ablation

We report a case of severe apical hypertrophic cardiomyopathy in order to discuss the nature of this unusual condition and the possibility of using selective alcohol ablation to effectively treat symptomatic hypertrophic cardiomyopathy that presents with apical aneurysm. A 73-year-old woman with severe, progressive dyspnea and intermittent chest pain was found to have localized left ventricular apical dyskinesia distal to an obstructive mid-distal muscular ring. The ring caused total systolic obliteration of the apical left ventricular cavity. Apical cavity pressure was extremely high, up to 330 mmHg—200 mmHg above that in the main left ventricular cavity. Because of the danger of apical rupture and clot formation, we attempted the experimental use of alcohol ablation for effective palliation. We present our pilot experience, offer a novel interpretation of the nature of this obscure entity, and possibly justify a new catheter treatment. In addition, we discuss the developmental, pathophysiologic, and clinical implications of this unusual form of hypertrophic cardiomyopathy. To our knowledge, ours is the first reported use of subselective, modified-protocol alcohol septal ablation to treat an obstructive mid-apical muscular ring in a patient with apical hypertrophic cardiomyopathy.Key words: Cardiomyopathy, hypertrophic/complications/epidemiology/physiopathology/therapy; ethanol/administration & dosage/therapeutic use; heart septum/pathology; hypertrophy, left ventricular/diagnosis; myocardial ischemia/complications; treatment outcomeHypertrophic obstructive cardiomyopathy (HOCM) is a congenital heart condition characterized by ventricular hypertrophy and a progressive worsening of symptoms, as related to the worsening of the subaortic gradient.^1,2 Either traditional surgical septal myomectomy^3,4 or alcohol septal ablation (ASA)^2,4,5 can be used to treat HOCM by effectively reducing the subaortic gradient.^1,2 We describe the case of an elderly woman who had the rarer variant of hypertrophic cardiomyopathy (HCM)—that with apical aneurysm and mid-ventricular obstruction. We describe in detail the experimental use of subselective alcohol ablation to treat the obstructive mid-apical muscular ring in this patient, and we revisit the nature of apical HCM.