Summary of BIDMC echo HCM/ Ethanol Ablation Protocol
Materials needed
1. 55-8 with S 3- ideally want tissue doppler but not on any WC unit .
2. two bottles of Optison- NOT DEFINITY- prob only will use one
3. 2 vent spikes
4. 2 1cc TB syringes ( cath lab usually has, but I bring just in case)
5. make sure optical disc in machine , with space.
Initial patient set-up
1.Set up machine in cath lab on right side of table- ie. Opposite the
catheterizers
2. Make sure you have good EKG – will need for looping/doppler etc.
3. Set Loop acquire format to full screen, not ususal quad. Change
loop settings to 2 beat length from our usual 1 beat.
--- Try to change machine set- up to auto store on loops.
Baseline:
1. acquire good 2D image of apical 4 chamber/ 4 chamber- identify
SAM /septal contact point.
2. Reconfirm resting gradient with imaging CW. Must be at least 50
mmHg at baseline or they will need Dobutamine. Tape and disc
acquire at least 3 gradients
3. Check for any gradients at any other levels, ie more distal, or
valvular AS.
4. Check apical 4, 5 and 2 chamber for degree of resting color MR
5. Drop the image depth to concentrate on mainly LV
6. Acquire disc and tape 3-4 complexes of trans MV inflow, sample
volume at MV tips, sweep speed for all spectra at 100- no calcs.
7. Do color m mode of MV inflow- again, sweep at 100,cursor in red
inflow. Aim is to get the whole slope of the E wave. 3-4 complexes.
No calculations- analysis will be off- line.
8. Switch preset to BIDMC TD = tissue doppler. Do tissue doppler at
lateral annulus on apical 4 chamber. Need good bi-phasic waves
below the baseline. Acquire for disc and tape- at least 3 good
complexes
9. If baseline gradient was not sufficient, they will do Dobutamine to
increase gradient and all of above has to be re-acquired on dobut.
10. Whatever dose( 5 or 10 mcgs ) that they use, that will be the
dose for f/u measurements too- at pre d/c, 3 months and 1 year.
It would not be a progressive dose DSE, just held at the 5 or 10
dose used in the cath lab.
Page 2
Actual CONTRAST and ABLATION recordings
1. have apical 5 chamber, LV maximized ( don’t need much atria)
2. switch the loop beat length to 10 beats.
3. Stay in harmonics- MGH does not drop the MI, nor do they use a
contrast pre-set. This allows you to be able to keep image more
easily- if used a contrast pre-set image too dark- couldn’t see
walls or SAM well.
4. AMNT-cath team will draw up full 3 ml vial of Optison and mix/ stir
in sterile bowl with 7 cc sterile saline (10ml total Optison & saline).
Then they will inject 0.4-0.5 ml of Optison/saline into coronary with
each injection of contrast.
5. Annotate first contrast injection as CON1 S1- on upper rt screen
6. Start taping as soon as they inject contrast, but start the loop
acquire only when they flush, or when the contrast shows up in the
myocardium.
7. Check quickly that RV free wall doesn’t light up just by angling
from the apical 5 more medially toward the RV free wall, then
swing into a 2 chamber and make sure inf wall not lighting up.
8. Assess efficacy of septal opacification- if not at correct level,or not
all the way out to the septal edge, then ask for another injection
9. If not at correct level and they change to another septal coronary,
the next injection would be CON2S2; If just a 2nd in same vessel,
then annotate as CON2S1 etc. Always recheck RV and inf wall
10.Post contrast, with balloon up, reassess gradient and label mid
screen- just the balloon being up may decrease gradient.
11.When it is time for the Ethanol, the first inject annotation isE1S1.
12.Again- acquire a 10 beat loop for disc.
13.Recheck gradients. Must have signif grad drop, or they will do
another alcohol injection = E2S1
Page 3 Post Ethanol Protocol- still in cath lab
This will be the immediate post procedure baseline.
Switch loop beats back to 2 beat loops from the 10
Tape and loop for disc 2D image of septal area
Document acute drop of gradient. – at least 3 complexes- 100 speed
Recheck for degree of color MR
Re- do color m-mode – 100 speed- no calcs.
Re do pw trans MV complexes- 100 speed- 2-3 complexes-no calcs.
Switch preset and do tissue doppler of lateral annulus- 3-4 complexes
Hit end of study
Store all loops on disc
Reset-machine presets at end of research protocol
These same recordings are repeated pre discharge ( about 48-72
hrs)
At 3 months
At 1 year.