經(jīng)皮間隔支化學(xué)消融治療肥厚梗阻性心肌病英文課件(模板)

IntroductionTreatmentofsymptomaticpatientswithHOCMaimstoreducesymptoms,improvefunctioncapacityandprovidebetterqualitylife.AimsdirectlytoreducethehypertrophiedinterventricularseptumwithconsecutiveexpansionoftheLVoutflowtractandreductionoftheLVoutflowtractgradientandimprovedistolicfunctionLV.Firstchoicedrugestreatment.

Atleast

10%

ofpatientswithmarkedoutflowtractobstructionhaveseveresymptoms,whichareunresponsivetomedicaltherapy.HOCMMyectomyDDD-PMICDPTSMAHypertrophiccardiomyopathyEpidemiologicalcharacteristicsHypertrophiccardiomyopathyincidenceof0.2%(1:500),0.16%inourcountry

.Thevastmajorityofpatientswithnosymptoms,

25%ofoutflowtractobstructionoccurredonlyabout5-10%ofpatientswithdrugtreatmentsfailorcauseserioussideeffectsofdrugseffectivedose.Requiretreatmentorsurgicalinterventioninpatientstreatedwithonlyveryfewparts.

PathophysiologicandclinicalcharacteristicsofHOCM

VentricularhypertrophyLeftventricularoutflowtractpressuregradientMyocardialischemia-anginapectoris.Arrhythmia-ventriculartachycardia,fibrillation.Clinicalmanifestations:dizziness,amaurosis,syncope,exertionalshortnessofbreath,anginapectoris,heartdisfunctionandsuddendeath.Generallyconsidered:moreseverehypertrophy,outflowtractobstructionneartheLVOTsit,themorehighertheobstructivepressuregradientwerethemoreobviousclinicalsymptomsandthegreaterthepotentialthreat.ThenaturalcourseofoutflowtractobstructionLevel–anyages.thereisabigdifferenceinNaturalhistoryThenaturalcoursenotsure.Themorecardiachypertrophy,thehigherthepressuregradient,thegreatertheriskofsuddendeath.

Theoutflowtractpressuregradientoftheclinicalimportanceoftheissueremainscontroversial,butitisgenerallyconsideredanimportantclinicalprocessindicators.Nnualmortalityrateof2-4%,theincidenceof

suddendeath≤1%

Thesymptoms

Whethertheobstructionproducedtheclinicalsymptoms?notonlywiththedegreeofoutflowtractobstructionandoutflowtractpressuregradient,aswellastheobstructionsite.Butalsowithventriculardiastolicfunctionandtheadequacyofvenousreturnisalsocloselyrelated.Increasetheheartbeforeandafterloadandmyocardialcontractilityoftencausenoticeableclinicalsymptoms.Therefore,itwillbecomemoreapparentafterexercise.Thepatientsshouldbetreatment.Diastolicdysfunction

Allpatientshaddiastolicdysfunction–HowthepressuregradientandsymptomsAndtheextentanddistributionofthehypertrophyhasnothingtodo.Whethernormalorsmallventricularcavity,duetoincreasedheartweight,ventricularvolumereduction,myocardialfibrosis,leavingventricularstiffnessincreased,compliancedecreasedandcausedthediastolicfunctiondamage.Pulmonaryvenouspressureandend-diastolicpressure

wereincreasedandheartdisfunction.systolicfunctionSystolicfunctionisnormalorsupranormalinHCOMBothobstructionandnon-obstruction,Systolicdysfunctionoccursinsmallsubset(10-15%)

Resultofprogressiveimpairmentofsystolicfunction.Thistransformation:wallthinning,cavitydilation,andfibrosis,increasedmortality11%(annual)andriskofSCD.ConventionalUCG,M-mode,orEF,fractionalshorteningpreserveddespiteimpaimentlong-axisfunctionTissueDopplerimage(TD)-derivedsystolicvelocities:inthebasalinferoseptalandanterolateralwallroutinelyinallpatientsonsubsequentscans.PTSMAindication(1)ClinicalindicationNodobutaminegradients(Drugs)CoronaryangiographyVerapamilRemoveballoonshouldbeemptyingalcoholoftheballooncatheterandstagnationinjectionalcoholOutflowtractobstructionsign

inEchocardiographSeptalthicknessHypertrophicCardiomyopathy

SurvivalAccordingtoOutflowTractGradientSystolicfunctionisnormalorsupranormalinHCOMMCEMorophologicindicationBeta-blockersasymmetricalseptalhypertrophy(ASH),2.Targetvesselsupplytonon-obstructionotherregionssuchas:papillarymuscle,freewall,etc.CONCLUSIONSBeta-blockersCONCLUSIONSCharacteristicsHypertrophiccardiomyopathyEpidemiologicalcharacteristicsMyocardialischemiaMyocardialischemia,thesymptomsofanginapectorisare:High-powersothatleftventricularmyocardialoxygenconsumptionincreased;Cardiaccontractionstrengthofoppressionthelargemyocardialcoronaryartery;Intramyocardialsmallcoronaryarterystenosisandintimalthickeningabnormalities,leadingtocardiachypertrophyandcoronaryarteryoxygenrequiredduetoanimbalanceofoxygensupply.Arrhythmiaandsuddendeath

HOCMofpatientswithabnormalmyocardialcellsandthearrangementofdisorderprovidesabasisforthearrhythmia.However,abnormalmyocardialarrangementandspontaneousarrhythmiasandventricularfibrillationthreshold,thepreciserelationshipisunclear.About25%ofpatientsmayhavenon-sustainedventriculartachycardia,thearrhythmiaissuddendeathofagoodpredictor,andnegativepredictiveaccuracyis97%.

RiskfactorsforsuddendeathHigh-risk:

1Suddendeathoccurredinasuccessfulrescue

2continuousmonomorphicventriculartachycardia

Clinicalriskfactors:

1non-sustainedventriculartachycardia

2movementabnormalbloodpressureresponse(≥25mmHg)

3unexplainedsyncope

4early-onsetfamilyhistoryofsuddendeath

5severeleftventricularhypertrophy>30mm

ThepurposeofthetreatmentPTMSA

TreatmentofsymptomaticpatientswithHOCMThePTMSAtreatmentofHOCMisaobstructionbyblockingathesupplybloodofpartsoftheseptalhypertrophyofmyocardialandmyocardialinjuryintheregion,leadingtotheareaofmyocardialnecrosis,myocardialcontractilefunctiondisappeared,Widenedtheleftventricularoutflowtract,whileloweringtheoutflowtractobstructionandthecardiacoutputincrease.Andimproveclinicalsymptomsandhemodynamics.PTSMAindication(1)ClinicalindicationSymptomaticpatientsDrugrefractoryseveresaideffectsmedicaltreatmentFunctionalclassIIIorIVFunctionalclassIIwithobjectivelimitationorriskfactorsRecurrentexercise-inducedsyncopesFailureofpriormyectomyorDDD-PMComorbitiywithincreasedsurgicalrisk.PTSMAindication(2)HemodynamicindicationinsymptomaticpatientsThepressuregradientatrest>50mmHgor>100mmHgwithprovocation.In2008ESCmeeting,SeggewisethatLVgradient≧30mmHgatrestorProvocableLVgradient≧60mmHg.ValsalvaPostextrasystole.Nodobutaminegradients(Drugs)

(ThereisnoinformationthatreducetheLVOTpressuretoreducesuddendeath,buttheLVOT>30mmHgandincreasedriskofdeathdirectlyrelatedto,NewEnglJMed2003;348:295-303)

HypertrophicCardiomyopathy

SurvivalAccordingtoOutflowTractGradientBJMaronetal;JAMA281:650-655,1999PTSMAindication(3)MorophologicindicationEchocariography

SubaorrticSAM-associatedgradientMid-cavitarygradientCaution:papillarymuscleinvolvement:MCENoprolongedmitralleafletsCoronaryangiographysuitableseptalbranch.Outflowtractobstructionsign

inEchocardiographM-modeechocardiograminobstructivehypertrophiccardiomyopathyshowingsystolicanteriormotionofthemitralvalve(SAM)(arrowsindicatingseptumandmitralvalveleafletcontact)

MorphologicofHOCMNewclassficationofHOCMMethods:theywereclassifiedinto4typesaccordingtotheechocardiographicresults:TypeI:localsubaorticobstructionofHOCM;TypeII:predominantinmidventicularobstruction;TypeIII:diffuseseptalhypertrophicobstructioninoutflowtractandmidventicularobstruction;TypeIV:multipositionhypertrophicobtruction.1.asymmetricalseptalhypertrophy(ASH),2.Idiopathichypertrophicsubaorticstenosis(IHSS),3.ApicalorJapaneseHCM.InthisformofnonobstructiveHCM,thethickestpartoftheleftventricleisatthetiporapexofthepump.4.theobstructionisnotintheoutflowtractbutinthemiddleoftheventricle.Atunnelleadsintoadilatedapicalportion,calledananeurysm,whichhasthinwalls.OurclassficationinPTSMAOurtypingintheI-typeandMaronintheI-typingwasthesameassuitableforPTSMAtreatmentandMaron'sII-typeincludesthetypeIIandtype

IIIofourmodel,itissuitablePTSMAtreatment.Therefore,ourIV-typeclassificationisthefirstmadebyultrasoundimagingfeaturesofHOCM,accordingtoitscharacteristicsinlinewithPTSMAtreatment.ArrhythmiaandsuddendeathClinicalindicationSeptalAblationinHOCM

AcuteResults/AblationTechniquePathophysiologicandclinicalcharacteristicsofHOCMCharacteristics(post-PTSMA6months)Thevesselcannotthoroughorincompleteablation(remainingsmallerbranches),self-revascularization.SeptalthicknessCharacteristicsTransitorytrifascicularblocksoccurredatarateof52.(PG=80mmHg)DiltiazemThevesselcannotthoroughorincompleteablation(remainingsmallerbranches),self-revascularization.ResultsofPTSMASeptalthicknessHypertrophicCardiomyopathy

SurvivalAccordingtoOutflowTractGradientIncreasetheheartbeforeandafterloadandmyocardialcontractilityoftencausenoticeableclinicalsymptoms.Complicationsinourpatientsasymmetricalseptalhypertrophy(ASH),2.Mergeotherneedssurgeryheartdisease

Mitralvalveabnormalitiesandtheirownformofpapillarymusclesinvolvedintheformationofpressuregradient,ormitralvalveprolapseandregurgitation.PTSMAcontraindicationsTarget

vessel

Selectablationofregionalimportance,particularlyinthetargetvesselisnotclearwhotheseptalbranch

Thefirstseptalbranchofthesizeanddistributionaregreatvariation

20%ofpatientsfirstbranchwassuppliedthefreewallofrightventricle

40%ofpatientswithsubaorticofseptalisnotcompletelysupportedbythefirstseptalbranch

5%ofpatientscannotdeterminethetargetvesseloftheregionContrastechocardiographymethod

inthetargetvesse

choiceInjectionofasmallamountofdye(1-2ml)throughtheguidewirelumenoftheinflatedballooncatheterangiographicallyPriortoalcoholinjection1-2mlofechocontrastmediumisadministeredthroughthecentrallumenoftheballooncatheterunderUCG.determinesthesupplyareaofthetargetseptalbranch.Ensurethatnoareasinvolvingnon-obstructive,suchasthepapillarymusclesandventricularfreewallandotherparts.Myocardial-Contrast-Echo

inHOCM

AvoidLADballooningExcludeLADleakageSeptalAblationinHOCM

Myocardial-Contrast-EchoLevovistIntheintervalofcontrastagentinjectedintothebranchtoobservethedistributionofvascularcontr

AlcoholShadow

LevovistshadowEchosequence:SubaorticseptumastargetbregionintypicalSAM-associated,subaorticobstraction,(Ddottedline),EtestinjectionoftheechocontrastagentinballoonofthethefirstsetalbranchofaforwardbranchofpositionhighlightingbebasalhalfofseptumplusaRVpapillarymuscle(whitearrows).Aftersuper-selectiveballoonofotherbranchoffirstseptalbranch.Correctopacification.MCEN=222NoMCEn=30PSeptalbranches(n)1.0±0.11.3±0.2<0.0001Alcohol(ml)2.9±0.93.9±2.4<0.0001Balloonsize(mm)1.9±0.42.4±0.2<0.0001CKmax(U/l)534±248745±420<0.001CK-MBmax(U/l)62±3096±62<0.0001H.Seggewissetal,49thScientificSessionsACC,2000SeptalAblationinHOCM

AcuteResults/AblationTechniqueH.Seggewissetal,49thScientificSessionsACC,2000SeptalAblationinHOCM

AcuteResults/AblationTechniquep<0.05p<0.01keysofTechnologyofPTSMA

Thekeytechnology:

identificationThepressuregradientatsubaorticandleftventricularidentificationsuitableoftargetseptalbranches.Mustbeinsertedtemporarypacemaker(topreventtheconductionblock).

Simultaneousmonitoringofaorticandleftventricularpressure.

Heparin(topreventcatheterinducedthrombosis).

AnalgesicGuidingcatheter:supportingflexibleandlowinjurySuitableOver-the-wireballooncatheterThekeysofTechnology

PTSMAIntraoperativeultrasoundmonitoringContrastechocardigraphyPaycloseattentiontothepressuregaugeunderfluoroscopy(observationballoonexpansionofstate).Injectionofalcoholdoseandspeeddeterminewhethershouldinjury(catheteroralcohol)andtheintervalbranchblock(necrosisstate)conditions1(withcomplications)or2septalbranches

ablationdidnotsignificantlyreducethepressure,andnoincreasealcoholdoseRemoveballoonshouldbeemptyingalcoholoftheballooncatheter

andstagnationinjectionalcohol(pre-PTSMA)Septalthickness(post-PTSMA3days)Mid-cavitarygradientTargetvesselsupplytonon-obstructionotherregionssuchas:papillarymuscle,freewall,etc.Priortoalcoholinjection1-2mlofechocontrastmediumisadministeredthroughthecentrallumenoftheballooncatheterunderUCG.Outflowtractobstructionsign

inEchocardiographAcutemitralregurgitationalsodidnotoccur.CONCLUSIONS43monthslater,90%ofthepatientsofthepressuregradientcompletelyeliminatedbyechocardiographic5mmandtoolong.MorphologicofHOCMTransitorytrifascicularblocksoccurredatarateof52.EchocariographyClinicalmanifestations:dizziness,amaurosis,syncope,exertionalshortnessofbreath,anginapectoris,heartdisfunctionandsuddendeath.Contrastechocardiographymethod

inthetargetvessechoiceClinicalindicationOutflowtractobstructionsign

inEchocardiographResultsofPTSMASystolicfunctionisnormalorsupranormalinHCOMSeptalthicknessContrastechocardigraphyAvoidLADballooningHypertrophiccardiomyopathyEpidemiologicalcharacteristicsContrastechocardiographycannotdeterminetargetvesselortheobstructionofregionalnosuitabletargetvessel.Doseofalcoholandspeed.(ThereisnoinformationthatreducetheLVOTpressuretoreducesuddendeath,buttheLVOT>30mmHgandincreasedriskofdeathdirectlyrelatedto,NewEnglJMed2003;348:295-303)FunctionalclassIIIorIVdeterminesthesupplyareaofthetargetseptalbranch.DDD-pacemaker:2-10%ResultsofPTSMAComplicationsinourpatientsApicalorJapaneseHCM.CharacteristicsThevesselcannotthoroughorincompleteablation(remainingsmallerbranches),self-revascularization.MorophologicindicationSystolicfunctionisnormalorsupranormalinHCOMThemorecardiachypertrophy,thehigherthepressuregradient,thegreatertheriskofsuddendeath.HypertrophicCardiomyopathy

SurvivalAccordingtoOutflowTractGradientClinicalindicationMustbeinsertedtemporarypacemaker(topreventtheconductionblock).(pre-PTSMA)A51-year-oldwoman’sLVOTgradientwasmonitoredcontinuouslyjustbeforetheballoonocclusion.(PG=80mmHg)LVAOHerLVOTgradient10minutesafterseptalablation（PG=12mmHg）LVAOA36-year-oldman’sLVOTgradienttestedbyDopplerechocardiographybeforePTSMA(PG=219mmHg)HisLVOTgradient6monthsafterPTSMA(PG=15mmHg)PG120mmHgbeforeprocedurePG=40mmHgafterinjectionof4.8mlalchoholGreatattentionEchocardiographyshowedventricularseptalhypertrophyover30mminHOCM,necessarytoperformeingPTSMAshouldbeverycautiousandcareful.Maybetherewereathickseptalbranch,andcontrolwide,and

collateral-richseptalbranchofsupport,treatmenthadahigherriskandimprovetheclinicalsymptomsandhemodynamicshavedifficulties,sosurgerymytomcemaybeabetterchoice.Itisverybigseptalbranch>2.5mmandtoolong.ThereisquitedangertoPTMSAPTSMAcontraindications

Nosignificantpressuregradientinhypertrophiccardiomyopathyorverydiffuseobstructive.

Mergeotherneedssurgeryheartdisease

Mitralvalveabnormalitiesandtheirownformofpapillarymusclesinvolvedintheformationofpressuregradient,ormitralvalveprolapseandregurgitation.

Contrastechocardiographycannotdeterminetargetvesselortheobstructionofregionalnosuitabletargetvessel.

Targetvesselsupplytonon-obstructionotherregionssuchas:papillarymuscle,freewall,etc.

NotsuitableOver-the-wireballoon.PTSMAcomplications(1)

Hospitalmortalityrate:1-2%DDD-pacemaker:2-10%

Myocardialinfarction

Reason:alcoholleakageintothepartsofinappropriate,collateralbranchopening,alcoholintotheinappropriatepartscauseno-reflow,LAD/LM/RCAinjury

Emergencysurgery

Reason:coronaryarteryinjury,acutemitralregurgitation(papillarymusclerupture)Bundlebranchblock:about50%andRBBB-basedPTSMAcomplications(2)

HeightorIII°-AVB

Factors:

whetherthemethodofapplicationofmyocardialcontrastechocardiography.

Doseofalcoholandspeed.Leftanteriordescendingarterydissection,coronarythrombosis,ventricularfibrillationandventriculartachycardia,acutemitralregurgitation,rightventricularinfarction,leftventricularfreewallinfarction.PTSMAshortcomings

Injuryoftheleftcoronaryarteryrequiredemergencybypassorstent

Cannotenterthetargetseptalbranch

CannotdeterminethetargetbranchofsupportFormitralandpapillarymuscleanomaliesandabnormalseptalhypertrophythebestchoicethesurgery

Mitralvalveinjuryrequiredemergencysurgery.

PermanentconductionblockoccurstreatmentshouldbePMTheseptalbranchwithgoodcollateralcirculation.DiastolicdysfunctionBeta-blockersThevastmajorityofpatientswithnosymptoms,PTSMAcomplications(2)(post-PTSMA3days)PTSMAindication(3)EchocardiographicobservationsplaysanimportantroleinthatwillhelptofinalizedefinethechoiceofseptalablationandtheablationefficacyandreducerisksandLong-termfollow-upoftreatmentefficacy.ComplicationsinourpatientsPG120mmHgbeforeprocedureFunctionalclassIIwithobjectivelimitationorriskfactorsClinicalindicationPatients(n=171)EchocariographyGenerallyconsidered:moreseverehypertrophy,outflowtractobstructionneartheLVOTsit,themorehighertheobstructivepressuregradientwerethemoreobviousclinicalsymptomsandthegreaterthepotentialthreat.DiltiazemHOCMMyectomyFormitralandpapillarymuscleanomaliesandabnormalseptalhypertrophythebestchoicethesurgery59%)underwentpermanentpacemakerimplantationduetopermanentcompleteAVblock.VerapamilMyocardial-Contrast-EchoinHOCMHerLVOTgradient10minutesafterseptalablation（PG=12mmHg）PTSMAlimitations

Someyoungpatientstoreducethepressuregradienteffectisnotsatisfactory,thepossiblereasons:Theseptalbranchwithgoodcollateralcirculation.Thevesselcannotthorough

orincompleteablation(remainingsmallerbranches),self-revascularization.Ahigherdegreeofseptalhypertrophy,ahigherdegreeoffibrosis,Partsoftheseptalablationscarformationpoor.

PTSMAin

FuwaiHospitalFromDec2000toMay2009,171patientsunderwentPTSMAinFuwaiHospital.Proceduresuccesswasachievedin141patients，successratewas82.6%.PatientCharacteristicsCharacteristicsPatients(n=171)Age(yrs)45.37±17.71Men/women122/49(71.35%/28.65%)SymptomsDyspnea93(54.39%)Angina73(42.69%)Syncope76(44.44%)NYHAfunctionalclass（II/III/IV）136(79.53%)/32(18.72%)/3(1.75%)Familyhistory42(24.6%)MedicationBeta-blockers106(62%)Verapamil52(30.4%)Diltiazem38(22.2%)Amiodanone13(7.6%)ResultsofPTSMAPTSMA(n=171)pSeptalthickness(pre-PTSMA)22.67±5.35mm

Septalthickness(post-PTSMA3days)20.68±4.61mmNSSeptalthickness(post-PTSMA6months)16.77±4.39mm<0.05LVOTPG(pre-PTSMA)97.58±38.23mmHgLVOTPG(post-PTSMA3days)52.36±35.7mmHg<0.001LVOTPG(post-PTSMA6months)47.26±38.62mmHg<0.001LADiameter(pre-PTSMA)43.78±7.33mm

LADiameter(post-PTSMA3days)42.41±7.52mmNSLADiameter(post-PTSMA6months)32.76±15.58mm<0.05ComplicationsinourpatientsIn-hospitaldeath

UptoMay2009,twopatientsdiedinthose171patients（1.17%）whounderwentPTSMAinFuwaiHospital.OnewasbecauseofalcoholleakagetotheLeftanteriordecendingartery,anotheroccurreddrug-inducedliverinjury.CompleteheartblockTransitorytrifascicularblocksoccurredatarateof

52.05%（89patients).

Onlyonepatient(0.59%)underwentpermanentpacemakerimplantationduetopermanentcompleteAVblock.ComplicationsinourpatientsOnepatient(0.59%)occurredventricularfibrillation,butherecoveredwellaftertheprocedure.Rightbundlebranchblockoccurredatarateof48.54%（83in171patients).NodissectionsoftheLMandLAD.NoemergencyCABGAcutemitralregurgitationalsodidnotoccur.Follow-upinourpatientsbyecho

Leftventricularoutflowtractpressuregradientwascontinuedtoasignificantdecreaseisanimportantfeature:Comparedwiththeacutephase,56%ofpatients3monthsrestingandstimulatethepressuregradientwillcontinuetodeclinefurther;Comparedwith3-monthperiod,43%ofpatientsoneyearthepressuregradientisstillfurtherreduced.After

3months40%ofpatientswithpressuregradientcompletelyreduced,ayearlaterthisvaluewaspromotedto62%.43monthslater,90%ofthepatientsofthepressuregradientcompletelyeliminatedbyechocardiographicCONCLUSIONSPTSMAisaneffectivenon-surgicalprocedureforsymptomaticpatientsandassociatedwithLVOTOinHOCMbecauseofitslowriskanditssignificanthemodynamicandsymptomaticimprovement.Ablationareashouldbeappropriate,assmallaspossible,toavoidalargescarformation.EchocardiographicobservationsplaysanimportantroleinthatwillhelptofinalizedefinethechoiceofseptalablationandtheablationefficacyandreducerisksandLong-termfollow-upoftreatmentefficacy

.Advice

Whohavenosymptomsormildsymptomsofthepatient,determinednottoconsiderthelinetoreduceoutflowtractobstructionofanytherapeuticinterventionmeasures(includingsurgicalandinterventionaltreatment)!!!PTSMAindication(1)ClinicalindicationSymptomaticpatientsDrugrefractoryseveresaideffectsmedicaltreatmentFunctionalclassIIIorIVFunctionalclassIIwithobjectivelimitationorriskfactorsRecurrentexercise-inducedsyncopesFailureofpriormyectomyorDDD-PMComorbitiywithincreasedsurgicalrisk.PTSMAindication(2)HemodynamicindicationinsymptomaticpatientsThepressuregradientatrest>50mmHgor>100mmHgwithprovocation.In2008ESCmeeting,SeggewisethatLVgradient≧30mmHgatrestorProvocableLVgradient≧60mmHg.ValsalvaPostextrasystole.Nodobutaminegradients(Drugs)

(ThereisnoinformationthatreducetheLVOTpressuretoreducesuddendeath,buttheLVOT>30mmHgandincreasedriskofdeathdirectlyrelatedto,NewEnglJMed2003;348:295-303)

HypertrophicCardiomyopathy

SurvivalAccordingtoOutflowTractGradientBJMaronetal;JAMA281:650-655,1999A36-year-oldman’sLVOTgradienttestedbyDopplerechocardiographybeforePTSMA(PG=219mmHg)PTSMAcontraindications

Nosignificantpressuregradientinhypertrophiccardiomyopathyorverydiffuseobstructive.

Mergeotherneedssurgeryheartdisease

Mitralvalveabnormalitiesandtheirownformofpapillarymusclesinvolvedintheformationofpressuregradient,ormitralvalveprolapseandregurgitation.

Contrastechocardiographycannotdeterminetargetve