Anorectic-induced valvulopathy

ject of debate for many years. The effectiveness of prophylactic treatment has not been tested in controlled studies. Therefore, treatment aimed at preventing the progression of disease does not appear justified in most asymptomatic patients. With regard to the well known side effects of medical therapy in hypertrophic cardiomyopathy and a small but important risk of late sudden atrioventricular block, drug treatment should be not given on a routine basis. In our hands the TASH procedure had a very impressive clinical success rate that compares favourably to the results of surgical myectomy and gives us the opportunity to individualize medical therapy after intervention. Interestingly, with regard to clinical success rate, substantial improvement in NYHA functional, exercise tolerance, maximal oxygen consumption, cardiac index at peak exercise and pulmonary artery mean pressure at workload, no significant differences were observed between the subgroup of patients that remained on medical therapy on a routine basis (patients 1–50) and the subgroup of patients treated with a more individualized post interventional medical regime. In conclusion, regardless of the intensity of the resting gradient, we restrict the TASH procedure to patients with a substantial provocable gradient and severe symptoms refractory to medical treatment, strongly recommend a functional approach that relies on ischaemia-induced gradient reduction before ethanol injection, and individualizes medical therapy after successful catheter intervention. We disagree with the suggestion given by Faber, that the use of intraprocedural echocardiography is a simple solution for most of the technical problems inherent in the catheterinterventional therapy of hypertrophic obstructive cardiomyopathy. For a safe and effective TASH procedure appropriate indication, profound knowledge of the disease and considerable technical expertise are required. These preconditions are fulfilled by Faber et al., who described a further decrease in lesion size after patient number 30. However, with regard to our experience and the examples drawn from the literature this indicates a learning curve, whereas myocardial contrast echocardiography added little to the overall positive clinical and haemodynamic results of transcoronary ablation of septal hypertrophy for hypertrophic obstructive cardiomyopathy.