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A 22-year-old man with a known family history of hypertrophic obstructive cardiomyopathy (HOCM) presents to the emergency department with an episode of syncope while climbing the stairs to get to his third-floor apartment. He was started on a beta-blocker twelve months ago but continued to have symptoms of dyspnea and lightheadedness. Verapamil was added six months ago, but he still has had persistent symptoms. What would be the next best step in the management of this patient?
(A) Cardiac transplantation
(B) ACE inhibitors
© Electrophysiology studies
(D) Surgical myomectomy
(E) Injection of absolute alcohol into the myocardium
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(E) Injection of absolute alcohol into the myocardium
Explanation:
When beta-blockers or negatively inotropic calcium blockers such as verapamil are not effective, the patient will most likely need an anatomic repair of his heart. ACE inhibitors are not only useless but can actually be dangerous by increasing left ventricular emptying and increasing the outflow tract obstruction. Cardiac transplantation should never be tried before a simple attempt at reducing the mass of the ventricular septum is made. Although surgical myomectomy is the traditional procedure, the septum can be reduced in size by using a catheter to inject absolute alcohol into the septal perforator branch of the left anterior descending artery to cause small therapeutic infarctions that will reduce the size of the septum. Although electrophysiological studies may indicate the need for the placement of a dual chamber pacemaker, the patient will still require a mechanical reduction of the myocardium to relieve what seems to be severe outflow tract obstruction
