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Avoiding Papillary Muscle Infarction With Myocardial Contrast Echocardiographic Guidance of Nonsurgical Septal Reduction Therapy for Hypertrophic Obstructive Cardiomyopathy

Originally published 2004;109:e27–e28

    Intracoronary 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.

    Figure 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.

    Figure 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).

    Figure 3. Cine 3; apical 2-chamber view (showing the anterior and inferior walls) showing Optison opacifying the basal area of the posterior papillary muscle.

    Figure 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.

    Figure 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.

    Figure 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.

    Figure 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

    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.


    Correspondence and reprint requests to Sherif F. Nagueh, MD, Section of Cardiology, 6550 Fannin St, SM-1246, Houston, TX 77030-2717. E-mail


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