Asymmetrical Septal Hypertrophy

Lies Dina Liastuti, MD Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, Jakarta

ASH
In classic HOCM, echocardiography demonstrates : ASH, LVOT narrowing, SAM of the Mitral leaflet Terms use to describe form of cardiomyopathy which causes outflow tract obstruction : IHSS,MSS,ASH,HOCM

The diagnostic criteria from echocardiography

Asymmetrical hypertrophy of the IVS SAM Anterior displacement of the MV & subvalvar apparatus Septal hypomobility Premature closure of the aortic valve Narrowing of the LVOT Abnormalities in LV chamber &LVOT architecture

The location of the ASH

Basal & mid portions of the anterior IVS, but may extend from the base to the apex (most common) confined to the proximal septum. Termed disproportionate upper septal thickening (DUST) apical septum , resulting in obliteration of the apex of the LV cavity (rare)

 The varying LV cavity geometry and outflow tract architecture impact differently on hemodynamics and symptom complex The altered LV geometry imposes on the ventricle an incoordinate pattern of contraction Not always patient with ASH demonstrate SAM

ASH with LVOT obstruction

Although there was no evidence of dynamic LVOT obstruction by clinical, echocardiographic,or catheterization criteria preoperatively, postoperative hemodynamic alterations could readily give rise to subvalvar obstruction in patients with LVH So,the dynamic obstruction does not become manifest until the postoperative period

Postoperative
LV systolic & diastolic internal dimension reduced LV contractility enhanced occurred as a result of afterload redduction and intravascular volume depletion lead to a smaller LVOT & increase in LVOT bloodflow velocity, venturi effect--SAM

Gradient can be provoked by :

Physiologic maneuvers (valsava) Pharmacologic interventions (nitrates ) Those will diminish LVED volume or Augment LV contractile state (isometric exercise and cathecolamines) Doppler : dagger shaped velocily signal

In the early postoperative period the functional obstruction is presipitated with :

LV afterload reduction the myocardium recovering from the effects of crossclamping the use of inopropic agents in the form of dopamine, dobutamine and calcium

Conclusions
A high index of suspicion of dynamic LVOT obstruction is waranted when a patient has hemodynamic deterioration early postoperative and fails to improve or worsens with inotropic treatment Once the diagnosis is made the appropriate th/ consists of maintaining LV volume by augmenting preload and afterload, and withdrawal of stimulation to contractility

Thank you