Kautzner Josef, Hašková Jana, Cvek Jakub, Adamíra Marek, Peichl Petr
Department of Cardiology, Institute for Clinical and Experimental Medicine, Vídeňská 1958/9, 14300 Prague 4, Czech Republic.
Department of Medicine 1, Palacky University Medical School, Palacky University Medical School Hospital, Zdravotníků 248/7, 77900 Olomouc, Czech Republic.
Eur Heart J Case Rep. 2024 Jul 30;8(8):ytae379. doi: 10.1093/ehjcr/ytae379. eCollection 2024 Aug.
Management of hypertrophic obstructive cardiomyopathy (HOCM) is often challenging, depending on clinical manifestation. This case report illustrates the complex treatment of HOCM with associated recurrent ventricular arrhythmias.
A 54-year-old female with HOCM diagnosed in 2012 underwent a failed attempt for alcohol septal ablation, implantation of an implantable cardioverter-defibrillator, and repeated radiofrequency ablations (including ablation of the septal bulge to reduce LV obstruction). For ventricular tachycardia (VT) recurrences, she had stereotactic arrhythmia radioablation with subsequent epicardial cryoablation from mini-thoracotomy, and endocardial ablation with pulsed field energy. The situation was finally solved by mechanical support and heart transplantation.
A few important lessons can be learned from the case. First, radiofrequency ablation was used successfully to decrease left outflow tract obstruction. Second, stereotactic radiotherapy has been used after four previous endo/epicardial catheter ablations to decrease the recurrences of VT. Third, mini-thoracotomy was used after previous epicardial ablation with subsequent adhesions to modify the epicardial substrate with cryoenergy. Fourth, pulsed field ablation of atrial fibrillation resulted in an excellent therapeutic effect. Fifth, pulsed field ablation was also used to modify the substrate for VT, and was complicated by transient AV block with haemodynamic deterioration requiring mechanical support. Finally, a heart transplant was the ultimate solution in the management of recurrent VT.
肥厚型梗阻性心肌病（HOCM）的治疗通常具有挑战性，这取决于临床表现。本病例报告阐述了伴有复发性室性心律失常的HOCM的复杂治疗过程。
一名于2012年被诊断为HOCM的54岁女性，酒精室间隔消融术、植入式心律转复除颤器植入术及多次射频消融术（包括消融室间隔膨出以减轻左心室梗阻）均告失败。对于室性心动过速（VT）复发，她接受了立体定向心律失常射频消融术，随后通过小切口开胸进行心外膜冷冻消融术，以及脉冲场能量心内膜消融术。最终通过机械支持和心脏移植解决了问题。
从该病例中可以吸取一些重要经验教训。首先，成功使用射频消融术降低左心室流出道梗阻。其次，在先前进行了四次心内膜/心外膜导管消融术后，采用立体定向放射治疗以减少VT复发。第三，在先前的心外膜消融术后因粘连，通过小切口开胸使用冷冻能量改变心外膜基质。第四，房颤的脉冲场消融产生了极佳的治疗效果。第五，脉冲场消融也用于改变VT的基质，但出现了短暂性房室传导阻滞并伴有血流动力学恶化，需要机械支持。最后，心脏移植是复发性VT治疗的最终解决方案。
