LAUSR

A 70-year-old woman diagnosed with hypertrophic cardiomyopathy (left ventricular outflow tract [LVOT] pressure gradient: 54 mmHg at rest, 70 mmHg under Valsalva’s maneuver) was scheduled for Percutaneous Transluminal Septal Myocardial Ablation (PTSMA). Coronary angiogram showed reverse angulation of the first major septal branch, and an eccentric calcified stenosis in the proximal left anterior descending (LAD) coronary artery (Fig. 1a). A first guidewire (Runthrough NS Extra Floppy, Terumo Corporation, Japan) was advanced to the distal LAD but we could not pass a second guidewire (SION blue, Asahi Intecc Co., Japan) into the first major septal branch assisted by a double-lumen microcatheter (Crusade, Kaneka Medix Co., Japan) because of extreme reverse angulation. The “reverse-wire technique” using a Crusade microcatheter with guidewire XT-R (Asahi Intecc) was successful (Fig. 1b) [1]. Thereafter, we failed to advance a microcatheter (Caravel, Asahi Intecc) into the first major septal branch because of a bulging calcified plaque in the septal branch ostium and ostial angulation (Fig. 1c). Therefore, rotational atherectomy was performed for plaque modification. We advanced a Rotawire Extra Support (Boston Scientific, USA) to the distal LAD, and performed rotational atherectomy with a 2.0-mm burr to the proximal LAD, including the septal branch ostium (Fig. 1d). Thereafter, 3.0 × 23 and 2.5 × 38 mm everolimus drug-eluting stents (Xience Alpine, Abbott Vascular, USA) were implanted at the distal LAD due to the dissection. The guidewire XT-R could now be advanced into the first major septal branch with the reversewire technique (Fig. 1e). A microcatheter was then advanced and an over-the-wire type balloon (2.0 × 12 mm, Emerge, Boston Scientific) was placed. After identifying the area supplied by the septal branch, 2.4 mL of desiccated ethanol was infused slowly through the inflated balloon. Finally, coronary angiography revealed no flow to the distal septal branch. After PTSMA, another 3.5 × 18 mm everolimus drug-eluting stent (Xience Alpine) was implanted at the proximal LAD. Final angiogram showed excellent expansion of the stented segment and occluded septal branch (Fig. 1f). Follow-up echocardiography showed marked improvement of the LVOT pressure gradient to 9 mmHg at rest. Cannulating the target septal branch is often difficult because of notable septal branch variation. In the present case, reverse angulation of the target septal branch and severely calcified stenosis were observed at the proximal LAD. Rotational atherectomy allowed plaque modification, enabling microcatheter passage and subsequent PTSMA.