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Shenouda J, Silber D, Subramaniam M, et al. Evaluation and Management of Concomitant Hypertrophic Obstructive Cardiomyopathy and Valvular Aortic Stenosis. Curr Treat Options Cardiovasc Med. 2016;18(3):17doi: 10.1007/s11936-016-0440-3.
Shenouda, J., Silber, D., Subramaniam, M., Alkhatib, B., Schwartz, R. K., Goncalves, J. A., & Naidu, S. S. (2016). Evaluation and Management of Concomitant Hypertrophic Obstructive Cardiomyopathy and Valvular Aortic Stenosis. Current treatment options in cardiovascular medicine, 18(3), 17. https://doi.org/10.1007/s11936-016-0440-3
Shenouda, John, et al. "Evaluation and Management of Concomitant Hypertrophic Obstructive Cardiomyopathy and Valvular Aortic Stenosis." Current treatment options in cardiovascular medicine vol. 18,3 (2016): 17. doi: https://doi.org/10.1007/s11936-016-0440-3
Shenouda J, Silber D, Subramaniam M, Alkhatib B, Schwartz RK, Goncalves JA, Naidu SS. Evaluation and Management of Concomitant Hypertrophic Obstructive Cardiomyopathy and Valvular Aortic Stenosis. Curr Treat Options Cardiovasc Med. 2016 Mar;18(3):17. doi: 10.1007/s11936-016-0440-3. PMID: 26874705.
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Curr Treat Options Cardiovasc Med. 2016 Mar;18(3):17. doi: 10.1007/s11936-016-0440-3.

Evaluation and Management of Concomitant Hypertrophic Obstructive Cardiomyopathy and Valvular Aortic Stenosis.

Current treatment options in cardiovascular medicine

John Shenouda, David Silber, Mythri Subramaniam, Basil Alkhatib, Richard K Schwartz, John A Goncalves, Srihari S Naidu

Affiliations

  1. From the Hypertrophic Cardiomyopathy Treatment Center and the Cardiac Catheterization Laboratory, Division of Cardiology, Winthrop University Hospital, 120 Mineola Blvd, Suite 500, Mineola, NY, 11501, USA.
  2. From the Hypertrophic Cardiomyopathy Treatment Center and the Cardiac Catheterization Laboratory, Division of Cardiology, Winthrop University Hospital, 120 Mineola Blvd, Suite 500, Mineola, NY, 11501, USA. [email protected].

PMID: 26874705 DOI: 10.1007/s11936-016-0440-3

Abstract

OPINION STATEMENT: The dilemma of the patient with both AS and LVOTO is now commonly encountered in clinical practice; indeed, physicians must be aware of the complex interaction and coexistent nature of both diseases, especially as both HOCM and TAVR have increased in awareness and prevalence. Importantly, the clinician must be aware of the complex interplay hemodynamically, with the two diseases confusing the TTE imaging and potentially affecting each other anatomically and clinically. There is no set guideline on how to approach this from a surgical or percutaneous approach, but we have outlined a set of recommendations which should serve the clinician and patient well. The three cases that are presented illustrate that methodical diagnosis in addition to the order of treatment do indeed matter. In the first case, there was AS and an underestimated LVOT gradient that was also present. Once the AS was corrected, the true LVOT gradient potential was evidenced and she decompensated, likely because there was a rapid decrease in afterload. Patients with concomitant LVOTO are not able to adjust quickly to the hemodynamic changes created by the rapid decline in afterload, as, for example, in HOCM patients who receive nitroglycerin. The second case demonstrated that when the LVOTO was severe and the AS nonsignificant (mild or moderate), the patient was able to live without symptoms for several years after successful alcohol septal ablation (ASA). She eventually needed an aortic valve and mitral valve replacement but that was postponed for several years until the AS became more significant, and the surgical risk was lowered by the elimination of the need for concomitant myectomy. In the last case, the patient was able to have both an ASA and TAVR within 3 months of each other without hemodynamic compromise. Indeed, this latter therapy sequence may be the best way to treat patients with both diseases in the future, as both ASA and TAVR continue to evolve into intermediate and lower-risk patient populations and the safety of ASA continues to be evident.

Keywords: ASA; Concomitant hypertrophic obstructive cardiomyopathy; Coronary artery disease; LVOTO; Valvular aortic stenosis

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