Thread by @alexsfelixecho

🧵 1/17 - Thread: Echo for Diagnosis and Management of obstructive HCM
Mechanisms of MR in these patients
Please, share your comments and experience

#echofirst #cardiotwitter #echothread
@NMerke @echo_stepbystep @iamritu @JaeKOh2 @dr_benoy_n_shah @EACVIPresident @StellEkaterina… twitter.com/i/web/status/1…

🧵 2/17 - Echo in obstructive HCM - Diagnosis / Management
✨Maneuvers (Valsalva, standing from Squatting) + Exercise Echo may unveil 33% latent obstructive HCM (37% rest -> 70% provocable)

@nat_echo @OAB1967 @echo_batman @papadocardio @robertomlang @fpmorcerf @mariovar55… twitter.com/i/web/status/1…

🧵 3/17 - In a study of Maron BJ et al - JACC 2016 with 573 HCM patients, patients with rest obstruction had more progressive HF (7,4%/year), followed by patients with provocable obstruction (3,2%/year) and less in nonobstructive HCM (1,6%/year)
sciencedirect.com/science/articl…… twitter.com/i/web/status/1…

🧵 4/17 - Exercise Echo in HCM is safe when performed in experienced centers: Cleveland Clinic - study with 263 HCM patients - major complications in <0,04% of patients (Drinko JK, et al. Am J Cardiol 2004)
✨Exercise Echo provides important prognostic information: in the study… twitter.com/i/web/status/1…

🧵 5/17 - There is no advantage to submit a patient with rest gradients > 50mmHg, only increased risks.
In this case there was already a LVOT gradient of 96mmHg, with mesossystolic Ao Valve closure in M-mode

#echofirst #cardiotwitter #echothread
@marciomp50 @echotalk… twitter.com/i/web/status/1…

🧵 5/17 - There is no advantage to submit a patient with rest gradients > 50mmHg, only increased risks.
In this case there was already a LVOT gradient of 96mmHg, with mesossystolic Ao Valve closure in M-mode

#echofirst #cardiotwitter #echothread
@marciomp50 @echotalk… twitter.com/i/web/status/1…

🧵 6/17 - SAM is the main mechanism of LVOT dynamic obstruction - "mitral-septal contact"
•SAM: not only result of septal asymmetric hypertrophy (⬆️Veloc / Venturi effect) 👉🏽 Crucial understanding for adequate treatment!
•Primary abnormalities of MV apparatus may have a great… twitter.com/i/web/status/1…

🧵 7/17 - Medioventricular LV obstruction is less frequent than LVOT obstruction, and has higher association with apical aneurysm, ventricular arrhythmia, embolic phenomena and death (Yan, L. R., et al. J Cardiovasc Med 2015, Liu, Q., et al. Scientific Reports 2017)
@purviparwani… twitter.com/i/web/status/1…

🧵 8/17 - ✨Apical aneurysm may occur in 2% of all patients with HCM (Maron MS, Circulation 2008), In 13-15% of patients with Apical HCM (Chen CC- Clin Cardiol. 2011) and 25% of patients with medioventricular obstruction (MVO) (Efthimiadis GK - Circ J. 2013).

⭐️In patients with… twitter.com/i/web/status/1…

🧵 9/17- There are multiple mechanisms responsible for MR occurrence in CMR: Basal ventricular septal hypertrophy + papillary muscles anomaly / subvalvar alterations, causing LVOT dynamic obstruction and leaflets lack of coaptation.

@RODRIGOVISCONT1 @EchoBielefeld… twitter.com/i/web/status/1…

🧵 10/17- The definition of grade and mechanism of MR in HCM is important for choosing the best therapeutic strategy.

💫Patients with septal hypertrophy ≤ 1.8cm or medioventricular obstruction may have important contribution of additional SAM causative mechanisms - consider… twitter.com/i/web/status/1…

🧵 11/17 - In 10% primary mitral valvular disease may coexist, bringing difficulties for MV repair - degenerative (prolapse / ruptured chordae) or traumatic fibrosis (repetitive septal contact) - Holst KA, et al. Mayo Clin Proc. 2019;94(1):66‐73.
@VerwerftJan @KardiologieHH… twitter.com/i/web/status/1…

🧵 12/17 - According to guidelines in symptomatic patients refractory to negative inotropic drugs (NYHA II-IV) septal reduction therapy (SRT) is indicated.
✨Evidence shows that early SRT is beneficial. Study by Cui H et al. The J Thorac and Cardiovasc Surg 2020 (n= 1351 patients… twitter.com/i/web/status/1…

🧵 13/17 Septal Myectomy - 😀low operative mortality in experienced centers.

✨Important improvement in symptoms and mortality when compared to nonoperated obstructive HCM patients - (Maron BJ - Ventricular Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy: Analysis… twitter.com/i/web/status/1…

🧵 14/17 - Intraprocedural Echo - Myectomy:
1- Evaluation of LVOT obstruction mechanism.
2- Localize the point of contact between interventricular septum and anterior mitra leaflet
2- MR mechanism?
3- Check for results after weaning from extracorporeal circulation - MR and… twitter.com/i/web/status/1…

🧵 15/17- Good results with Alcohol Septal Ablation has been published - Euro ASA registry:
•1275 symptomatic patients (NYHA III-IV)
•Gradients LVT > 50mmHg rest or efforts
•Without significant mitral valve disease
•1% mortality in 1 month
•12% needed pacemaker implantation… twitter.com/i/web/status/1…

🧵 16/17 - Intraprocedural Echo for Alcohol septal Ablation:
✨Evaluate perfused area for each septal branch: use of intracoronary contrast (UEA) - reduces infarction area, less complete AV block, better final result.
✨TTE or TEE may be used
✨Evaluate immediate results of… twitter.com/i/web/status/1…

🧵 17/17 - Myosin Inhibitors - Mavacantem
Phase 3 trial
Pimary endpoint (Primary endpoints: improvement of peak O2 consumption (pVO2) 1,5ml/Kg/min + improvement of functional class (FC) or improvement of pVO2 > 3,0ml/Kg/min without FC deterioration) : 37% Mavacantem group x 17%… twitter.com/i/web/status/1…

@pabeda1

🧵 5/17 - There is no advantage to submit a patient with rest gradients > 50mmHg, only increased risks.
In this case there was already a LVOT gradient of 96mmHg, with mesossystolic Ao Valve closure in M-mode

#echofirst #cardiotwitter #echothread
@marciomp50 @echotalk… twitter.com/i/web/status/1…

🧵 6/17 - SAM is the main mechanism of LVOT dynamic obstruction - "mitral-septal contact"
•SAM: not only result of septal asymmetric hypertrophy (⬆️Veloc / Venturi effect) 👉🏽 Crucial understanding for adequate treatment!
•Primary abnormalities of MV apparatus may have a great… twitter.com/i/web/status/1…

🧵 7/17 - Medioventricular LV obstruction is less frequent than LVOT obstruction, and has higher association with apical aneurysm, ventricular arrhythmia, embolic phenomena and death (Yan, L. R., et al. J Cardiovasc Med 2015, Liu, Q., et al. Scientific Reports 2017)
@purviparwani… twitter.com/i/web/status/1…

🧵 8/17 - ✨Apical aneurysm may occur in 2% of all patients with HCM (Maron MS, Circulation 2008), In 13-15% of patients with Apical HCM (Chen CC- Clin Cardiol. 2011) and 25% of patients with medioventricular obstruction (MVO) (Efthimiadis GK - Circ J. 2013).

⭐️In patients with… twitter.com/i/web/status/1…

🧵 9/17- There are multiple mechanisms responsible for MR occurrence in CMR: Basal ventricular septal hypertrophy + papillary muscles anomaly / subvalvar alterations, causing LVOT dynamic obstruction and leaflets lack of coaptation.

@RODRIGOVISCONT1 @EchoBielefeld… twitter.com/i/web/status/1…

🧵 10/17- The definition of grade and mechanism of MR in HCM is important for choosing the best therapeutic strategy.

💫Patients with septal hypertrophy ≤ 1.8cm or medioventricular obstruction may have important contribution of additional SAM causative mechanisms - consider… twitter.com/i/web/status/1…

🧵 11/17 - In 10% primary mitral valvular disease may coexist, bringing difficulties for MV repair - degenerative (prolapse / ruptured chordae) or traumatic fibrosis (repetitive septal contact) - Holst KA, et al. Mayo Clin Proc. 2019;94(1):66‐73.
@VerwerftJan @KardiologieHH… twitter.com/i/web/status/1…

🧵 12/17 - According to guidelines in symptomatic patients refractory to negative inotropic drugs (NYHA II-IV) septal reduction therapy (SRT) is indicated.
✨Evidence shows that early SRT is beneficial. Study by Cui H et al. The J Thorac and Cardiovasc Surg 2020 (n= 1351 patients… twitter.com/i/web/status/1…

🧵 13/17 Septal Myectomy - 😀low operative mortality in experienced centers.

✨Important improvement in symptoms and mortality when compared to nonoperated obstructive HCM patients - (Maron BJ - Ventricular Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy: Analysis… twitter.com/i/web/status/1…

🧵 14/17 - Intraprocedural Echo - Myectomy:
1- Evaluation of LVOT obstruction mechanism.
2- Localize the point of contact between interventricular septum and anterior mitra leaflet
2- MR mechanism?
3- Check for results after weaning from extracorporeal circulation - MR and… twitter.com/i/web/status/1…

🧵 15/17- Good results with Alcohol Septal Ablation has been published - Euro ASA registry:
•1275 symptomatic patients (NYHA III-IV)
•Gradients LVT > 50mmHg rest or efforts
•Without significant mitral valve disease
•1% mortality in 1 month
•12% needed pacemaker implantation… twitter.com/i/web/status/1…

🧵 16/17 - Intraprocedural Echo for Alcohol septal Ablation:
✨Evaluate perfused area for each septal branch: use of intracoronary contrast (UEA) - reduces infarction area, less complete AV block, better final result.
✨TTE or TEE may be used
✨Evaluate immediate results of… twitter.com/i/web/status/1…

🧵 17/17 - Myosin Inhibitors - Mavacantem
Phase 3 trial
Pimary endpoint (Primary endpoints: improvement of peak O2 consumption (pVO2) 1,5ml/Kg/min + improvement of functional class (FC) or improvement of pVO2 > 3,0ml/Kg/min without FC deterioration) : 37% Mavacantem group x 17%… twitter.com/i/web/status/1…