Introduction: Percutaneous transluminal septal myocardial ablation (PTSMA) is an established treatment for patients with symptomatic hypertrophic obstructive cardiomyopathy (HOCM) for patients’ refractory to medical therapy. However, combined percutaneous catheter-based interventions for HOCM and coronary artery disease (CAD) have seldom been described, despite a higher associated CAD in patients with HOCM but none have used intravascular imaging (optical coherence tomography-OCT). Herein, we report a case being treated with simultaneous percutaneous transluminal coronary angioplasty (PTCA) under OCT guidance for a calcific left anterior descending stenosis and PTSMA for symptomatic HOCM, the current state of art management regimen.

Case Report: A 56‑year‑old male presented with dyspnea on exertion NYHA Class III for 1 week. The results of echocardiography were consistent with typical HOCM with a LVOTPG of 55mmHg. He was subsequently admitted for coronary angiography (CAG) to determine the associated CAD, if any, and to define the septal perforator to work on. A radial CAG showed 80%–90% calcific stenosis of the LAD coronary artery distal to the 3rd major septal perforator. Therefore, PTCA to LAD with intravascular imaging combined with PTSMA was chosen to treat his symptoms. Post-stenting, OCT pullback revealed a malapposed stent at the proximal edge without any edge dissections, for which further post dilatation was done. Subsequently, PTSMA was done successfully. After PTSMA, check CAG of the left coronary artery revealed no flow in the first septal branch and 2DEcho revealed a left ventricular outflow tract pressure gradient(LVOTPG) of 15 mmHg with no significant MR. The recovery after the procedure was favorable and no electrocardiogram abnormality occurred after the procedure. The patient was discharged on Day 3 after the procedure.

Discussion: The prevalence of critical CAD in patients with HOCM varies between 11% and 26%. The mortality rate of HOCM patients with critical CAD is 6.6% per year, which greatly exceeds the mortality rate of general HOCM populations which is <1% per year. There are only some case reports of HOCM combined with critical CAD treated simultaneously with both PTSMA and PTCA. We present the first case of HOCM with critical calcific coronary artery stenosis treated simultaneously with PTSMA and PTCA using state‑of‑the‑art intravascular imaging (OCT). In our case, the LVOTPG was reduced from 55 mmHg to 15 mmHg with a significant reduction of MR. PTSMA has both immediate and long‑term therapeutic effects. Our case report highlights a couple of frequently asked questions concerning HOCM associated with critical calcific CAD. This report shows that taking into account the surgery‑related risks and the advancements in the field of percutaneous interventions including IVI‑guided PTCA, it appears that simultaneous percutaneous interventional therapy is a safe, feasible, and effective approach in patients with HOCM combined with critical CAD, especially if intravascular imaging is applied.

Conclusion: This case report demonstrates that simultaneous percutaneous treatment of HOCM associated with critical calcific LAD stenosis with PTCA and PTSMA is safe and effective. 

Mastebhakti Bhavana has completed her Cardiology super specialization from Delhi, India and is currently working as an Associate Consultant, Interventional Cardiology at Fortis Escorts Heart Institute, Delhi, India.