Clinical characteristics and outcomes of alcohol septal ablation in the era of transcatheter valve interventions.

BACKGROUND: The clinical efficacy and safety of alcohol septal ablation (ASA) for obstructive hypertrophic cardiomyopathy (HCM) have been well-established; however, less is known about outcomes in patients undergoing preemptive ASA before transcatheter mitral valve replacement (TMVR). AIMS: The goal of this study is to characterize the procedural characteristics and examine the clinical outcomes of ASA in both HCM and pre-TMVR. METHODS: This retrospective study compared procedural characteristics and outcomes in patient who underwent ASA for HCM and TMVR. RESULTS: In total, 137 patients were included, 86 in the HCM group and 51 in the TMVR group. The intraventricular septal thickness (mean 1.8 vs. 1.2 cm; p < 0.0001) and the pre-ASA LVOT gradient (73.6 vs. 33.8 mmHg; p ≤ 0.001) were higher in the HCM group vs the TMVR group. The mean volume of ethanol injected was higher (mean 2.4 vs. 1.7 cc; p < 0.0001). The average neo-left ventricular outflow tract area increased significantly after ASA in the patients undergoing TMVR (99.2 ± 83.37 mm2 vs. 196.5 ± 114.55 mm2; p = <0.0001). The HCM group had a greater reduction in the LVOT gradient after ASA vs the TMVR group (49.3 vs. 18 mmHg; p = 0.0040). The primary composite endpoint was higher in the TMVR group versus the HCM group (50.9% vs. 25.6%; p = 0.0404) and had a higher incidence of new permanent pacemaker (PPM) (25.5% vs. 18.6%; p = 0.3402). The TMVR group had a higher rate of all-cause mortality (9.8% vs. 1.2%; p = 0.0268). CONCLUSIONS: Preemptive ASA before TMVR was performed in patients with higher degree of clinical comorbidities, and correspondingly is associated with worse short-term clinical outcomes in comparison to ASA for HCM patients. ASA before TMVR enabled percutaneous mitral interventions in a small but significant minority of patients that would have otherwise been excluded. The degree of LVOT and neoLVOT area increase is significant and predictable.

Wilkie's Weight Loss Wonder, A Case Series.

INTRODUCTION: Wilkie's Syndrome, also known as Superior Mesenteric Artery Syndrome (SMAS), is a rare cause of bowel obstruction that can contribute to vague abdominal symptoms on clinical presentation. This syndrome occurs when the aortomesenteric angle decreases, compressing the third portion of the duodenum between the aorta and the superior mesenteric artery. An acute decrease in the mesenteric fat pad cushion between these two blood vessels is the primary etiology, although other causes (e.g., anatomical, postoperative, functional, and pubescent etiologies) have also been described. CASE PRESENTATION: In the present cases, 2 females with a common history of recent weight loss presented to our institution with similar symptoms of abdominal pain, nausea and vomiting. Each patient was subsequently diagnosed with SMAS following imaging studies. Both patients experienced successful resolution of symptoms with conservative nutritional management. DISCUSSION: Common presenting complaints of SMAS include nausea, vomiting, early satiety and postprandial pain. These symptoms overlap with other gastrointestinal disorders (i.e., mesenteric ischemia, intestinal volvulus, peptic ulcer disease) making diagnosis difficult. SMAS can be identified through imaging modalities including barium studies and computer tomography. First line therapies typically include conservative nutritional support and promotion of weight gain. If conservative therapies fail, various surgical procedures can be pursued. Delayed diagnosis can lead to further pathological sequelae, including duodenal compromise, ischemia and necrosis. As the syndrome progresses, success of conservative nutritional support is less likely, and surgical correction becomes increasingly necessary. CONCLUSION: Therefore, a clinical goal for SMAS should include as swift a recognition and diagnosis as possible.