case_images: PMC10646534_01
case_images: (Aa) Preoperative transthoracic echocardiography (TTE): left ventricular (LV) septal thickness of 20mm; (Ab) the extent of ventricular aneurysm; (Ac) left ventricular outflow tract (LVOT) obstruction at rest; (Ad) reduced strain value of local LV apex by strain echocardiography (SE). (B) LV apical entrance of the ablation needle guided by TTE. (C) Bi-plane showing ablation needle position. (Da) LV septal thickness of 12 mm after ablation; (Db) myocardial contrast-enhanced echocardiography (MCE) showing a contrast filling defect in the ablation zone; (Dc) LVOT gradient of 20 mm Hg after the ablation; (Dd) LV apical systolic synchrony detected by SE.
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case_images: PMC10646534_01_fcvm-10-1278457-g001.jpg
case_images: F1
case_images: Pre-operative STE demonstrated the lowest strain value in the basal interventricular septum, decreasing to -5.9%, and the lowest strain value in the left ventricular apex, decreasing to -11.9% (Figure 1A). TTE, in which the approach was reverse insertion to avoid pericardial tamponade caused by insertion into the left ventricle (Figure 1B). The location and characteristics of the aneurysm necessitated a specific approach when choosing the Liwen procedure. The presence of the ventricular aneurysm compelled us to pay special attention to the insertion direction and needle tip placement within the aneurysmal myocardium during the Liwen procedure to avoid inadvertent entry into the cardiac chamber and the risk of pericardial tamponade (Figure 1C). STE showed LV systolic synchrony was achieved, and the apical aneurysm returned to normal appearance of morphology (Figure 1D).
case_images: (A) Preoperational cardiac magnetic resonance imaging (MRI). (a) Thickened interventricular septum, (b) the extent of ventricular aneurysm, (c) myocardial interstitial fibrosis; (B) post-operational cardiac MRI. (a) Interventricular septal thickness, (b) hypoperfusion area of myocardium at the base of ventricular septum; (C) recovered strain values of local LV apex post-operation; (D) electrocardiogram post-operation; (E) sudden cardiac death score pre- and post-operation; (F) stress echocardiographic parameters of pre- and post-operation.
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case_images: PMC10646534_01_fcvm-10-1278457-g002.jpg
case_images: F2
case_images: Cardiac magnetic resonance imaging (MRI) findings suggested a diagnosis of hypertrophic cardiomyopathy with asymmetrical myocardial hypertrophy, interstitial fibrosis, and left ventricular outflow tract (LVOT) obstruction (Figure 2A). T-wave changes in the same leads. The patient was classified as NYHA III in terms of functional capacity (Figure 2E). One year post the procedure, STE showed an increase in strain values in the basal interventricular septum, reaching -17.5%, and a significant recovery in strain value in the left ventricular apex, returning -22.3%" (with the anterior wall as a reference) (Figure 2B). However, 1 year after the procedure, stress echocardiography showed a reduced flow velocity in the LVOT, with a peak velocity of 2.5 m/s and a peak pressure gradient of 25 mmHg (Figure 2F). Follow-up electrocardiograms at 1 year and 2 years post-procedure continued to show sinus rhythm with horizontal ST-segment depression of 0.05-0.15 mv in leads I, II, avF, and V3-V6, with a P-wave duration of 122 ms (Figure 2C).