Relation of Immediate Decrease in Ventricular Septal Strain After Alcohol Septal Ablation for Obstructive Hypertrophic Cardiomyopathy to Long-Term Reduction in Left Ventricular Outflow Tract Pressure Gradient Jan van Ramshorst, MD, Sjoerd A. Mollema, MD, Victoria Delgado, MD, Ernst E. van der Wall, MD, PhD, Martin J. Schalij, MD, PhD, Douwe E. Atsma, MD, PhD, and Jeroen J. Bax, MD, PhD* Alcohol septal ablation (ASA) aims to decrease left ventricular outflow tract (LVOT) obstruction in patients with obstructive hypertrophic cardiomyopathy (HC). To date, no diagnostic variables at baseline are available to predict long-term success of the procedure. We hypothesized that an immediate decrease in septal longitudinal strain after ASA would be associated with sustained LVOT gradient decrease after 6 months. ASA was performed in 22 patients with HC and severe drug-refractory symptoms. Clinical evaluation and 2-dimensional echocardiography were performed before, 1 day after, and 6 months after ASA. During 6-month follow-up, New York Heart Association class improved (2.7  0.5 vs 1.4  0.6, p <0.01) and LVOT gradient decreased (68  31 vs 21  21 mm Hg, p <0.01). Strain evaluation showed considerable decreases in basal septal strain (12  3% vs 8  2%, p <0.01) and midseptal strain (13  4% vs 8  3%, p <0.01) 1 day after ASA. Decreases in basal septal and midseptal strain 1 day after ASA were strongly related to the decrease in LVOT gradient during 6-month follow-up (r  0.70, p <0.01, and r  0.65, p <0.01, respectively). In conclusion, in patients with HC and severe drug-refractory symptoms, immediate decrease in septal strain after ASA is strongly related to a decrease in LVOT gradient after 6 months and might therefore serve as an early determinant for long-term success of the ASA procedure. © 2009 Elsevier Inc. (Am J Cardiol 2009;103: 1592–1597) Myocardial strain measures active tissue deformation and reflects regional myocardial function. 1 In infarcted myocardium, an immediate decrease in contractility occurs, with an acute decrease in myocardial strain. 2 Accordingly, it was hypothesized that an immediate decrease of septal lon- gitudinal strain after alcohol septal ablation (ASA) would be associated with a decrease in left ventricular outflow tract (LVOT) gradient after 6 months of follow-up in patients with obstructive hypertrophic cardiomyopathy (HC). In the present study, the relation between the decrease in septal strain at 1 day after ASA and the change in LVOT gradient at 6 months was evaluated. In addition, extensive echocar- diographic evaluation of patients undergoing ASA was per- formed, including global left ventricular (LV) and right ventricular (RV) strain analysis. Myocardial strain was eval- uated using novel echocardiographic techniques including automated function imaging analysis and speckle tracking 2-dimensional strain analysis. Methods Twenty-two consecutive patients were treated with ech- ocardiography-guided ASA. Diagnosis of obstructive HC was based on established clinical and echocardiographic criteria. 3 Patients were eligible for ASA if severe drug- refractory symptoms existed (dyspnea New York Heart As- sociation class III to IV, angina Canadian Cardiovascular Society class 3 to 4, or recurrent exercise-induced syncope) and LVOT gradient exceeded 50 mm Hg at rest or 100 mm Hg during exercise as documented by Doppler echocardi- ography. All patients underwent 2-dimensional echocardi- ography within 1 month before ASA, the day after ASA, and at follow-up (25  5 weeks). New York Heart Association class was assessed at baseline and 6-month follow-up. In all patients, a 4Fr temporary pacemaker electrode was positioned in the right ventricle. A 6Fr right coronary Jud- kins catheter was placed in the LV cavity, and a 6Fr guiding catheter was positioned in the ostium of the left main cor- onary artery. LVOT pressure gradient was monitored con- tinuously throughout the procedure. After left coronary ar- tery angiography, a 0.014-inch guidewire was advanced into the target septal perforating artery. A 1.5- to 2.5-  10-mm over-the-wire balloon was then introduced into this septal branch. After inflation of the balloon at the origin of the septal branch, x-ray contrast was injected through the shaft of the balloon to exclude retrograde leakage of injected fluid Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands. Manuscript received October 23, 2008; revised manu- script received and accepted January 31, 2009. Dr. Bax received supporting grants from Medtronic, Boston Scientific, BMS Medical Imaging, St. Jude Medical, Edwards Lifesciences, and GE Healthcare. *Corresponding author: Tel: 3171-526-2020; fax: 3171-526-6809. E-mail address: j.j.bax@lumc.nl (J.J. Bax). 0002-9149/09/$ – see front matter © 2009 Elsevier Inc. www.AJConline.org doi:10.1016/j.amjcard.2009.01.373