A 52-year-old female with hypertension and hypertrophic obstructive cardiomyopathy (HOCM) presented with acute left ventricular failure. Medical management failed to relieve her exertional angina symptoms. Angiography showed no obstructive lesions but a lesion was suspected at the left main ostium. Fractional flow reserve (FFR) of the left main was inconclusive. Optical coherence tomography (OCT) of the left main showed plaque but no significant stenosis. The patient ultimately underwent septal myectomy surgery but developed a postoperative ventricular septal defect requiring re-surgery. She later required a permanent pacemaker and remains asymptomatic currently. This case demonstrates the challenges in managing HOCM and limitations of diagnostic techniques like FFR

1. Dilemma in case of HOCM
Dr. Vivek mandurke
Interventional cardiologist

2. • 52 yr female
• Hypertensive
• k/c/o HOCM
• Exertional angina CCS class III
• Presented with acute LVF
• ECG : LBBB with QRS – 140 ms
• ECHO

6. • Pt shifted from periphery hospital with acute LVF
• Managed with Oxygen, Lasix infusion
• Pt improved over 72 hours
• Shifted to ward
• After every meal she use to have tachycardia, dyspnoea and fall in
saturation
• Pt twice shifted to ICU twice as saturation fall below 90
• Pt was on optimised doses of betablockers CCB diuretics
• Pt added on SGLT2 inhibitor
• Still no relief … medical management failed to relieve her symptoms

8. • We planned to do CAG to rule out any obstructive lesion

10. Proximal LAD – no septal perforator

11. Ventriculisaton with 5F catheter so attempt
made to visualise ostium of left main

12. We thought definitely there is lesion at
ostium of left main

13. What next …
• Evaluate further this Lesion
• Physiological study vs imaging/ direct stenting
• We opted for FFR with iv adenosine

14. FFR to left main to LAD

15. What next….
• We decided to do left main stenting with imaging as confused even
after FFR
• Default strategy was IVUS but machine not working
• Difficult to visualise ostial segment of LM with OCT
• We decided to use TELESCOPE

17. Ostium of left main looks fairly good with
eccentric plaque

18. • After looking OCT we abandoned plan of left main stenting
• Limited Literature - FFR in HOCM

19. Finally decided to go for surgery

20. Risk for Septal reduction therapy

21. Intraop TEE before myectomy

22. Intraop TEE after myectomy

23. Hushhh…Pt discharged on 7th day of surgery

24. Echo on discharge

25. But all izz not well …
• Pt came with acute LVF after 9th day of discharge ...
• Done echo and got surprize

26. No SAM

29. Post myectomy VSD ..

30. Finally decided to go for redo surgery

32. All izz still not well…
• Pt went into CHB post operative
• Decided to go for permanent pacemaker

34. Date of admission 10/11/21
Cag 13/11/21
FFR 16/11/21
OCT 19/11/21
Surgical myectomy 25/11/21
Discharged on 1/12/21
Re-admission and Detection of VSR with acute LVF 9/12/21
Dacron Patch closure of VSD 11/12/21
PPMI 18/12/21
Asymptomatic till date …..

35. Learning points
• Management of HCM is very challenging
• Every ventriculisation is not significant lesion
• Limited literature about FFR in HOCM
• Surgery though better than alcohol septal ablation for long run … still
it is last resort