PMC6305023_01
(a) The first septal branch was confirmed beforehand. (b) Tip injection into the septal branch using a 2 mm balloon. (c) Total occlusion of the septal branch was confirmed after alcohol injection. (d) Transesophageal echocardiography confirmed the perfusion area of the septal branch as a bright area by contrast injection. (e) Alcohol was administered into the septal branch. (f) Finally, pressure gradient at the left ventricular outflow tract was decreased.
CRIC2018-5026190.001.jpg
PMC6305023_01_CRIC2018-5026190.001.jpg
fig1
Coronary angiography confirmed the first major septal branch perfusing the basal septum (Figure 1(a)). Through a 2 mm over-the-wire balloon, microbubble contrast was injected into the first septal branch to confirm its perfusion area in the septum, which was located on the opposite side of SAM, using TEE (Figure 1(d)). After injecting a total of 3.5 ml absolute alcohol into the septal branch (Figure 1(e)), total occlusion was confirmed by coronary angiography (Figure 1(c)), and the pressure gradient at the LVOT was decreased below 10 mmHg (Figure 1(f)).
(a-c) No systolic anterior motion (SAM) was observed before transcatheter aortic valve implantation (TAVI). (d-f) Five minutes after TAVI, there was no SAM or pressure gradient. (g) Fifteen minutes later, SAM clearly emerged. (h) Transthoracic echocardiography showed severe mitral regurgitation. (i) Pressure gradient was >50 mmHg at the left ventricular outflow tract.
CRIC2018-5026190.002.jpg
PMC6305023_01_CRIC2018-5026190.002.jpg
fig2
Five minutes after implantation, there was no obvious LVOT obstruction and SAM (Figures 2(d)-2(f)). However, 15 minutes later, TEE clearly showed SAM and severe MR, and pressure gradient was >50 mmHg at the LVOT, even under increased dose of beta-blockers (Figures 2(g)-2(i)).