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Recurrent Obstruction After Percutaneous Plication in Hypertrophic Cardiomyopathy
Recurrent Obstruction After Percutaneous Plication in Hypertrophic Cardiomyopathy Paul Sorajja, MD
An 82-year-old woman, who was previously treated successfully with percutaneous plication for obstructive hypertrophic cardiomyopathy (HCM) with the MitraClip (Abbott Vascular, Santa Clara, CA), returned 9 months later with severe, drug-refractory symptoms. A, Transesophageal echocardiogram (TEE) shows the previously placed clip in place (arrowhead), and normal laminar flow near its position (arrow). B, Three-dimensional TEE from the left atrium (i.e., surgeon’s view) shows the position of previously placed MitraClip on the A2-P2 segments of the mitral valve (MV) and the associated tissue bridge (arrowhead). However, with further imaging, she had evidence of residual left ventricular outflow tract (LVOT) obstruction due to systolic anterior motion (SAM) of the A1 segment of the MV. C, End-diastolic image on TEE shows patency of the LVOT (arrow) during diastole and no SAM (arrowheads). D, However, SAM is present during systole with flow acceleration (arrowheads). The lateral mitral orifice was too small for additional percutaneous plication, and her mean MV gradient was 4 mm Hg. She therefore underwent alcohol septal ablation. E, Coronary angiography of the left coronary artery shows a large proximal septal perforator (arrowhead). F, Using conventional techniques for alcohol septal ablation, 1.7 mL of desiccated alcohol is injected into this proximal branch of this septal artery for ablation (arrowhead). G, Initial contrast echocardiography demonstrated the distal branch of the septal artery to supply a region of the myocardium too remote from the site of LVOT obstruction (arrow). H, Thus the balloon
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catheter was repositioned in the proximal branch, where contrast injection demonstrated an appropriate location for the ablation. I, At baseline, the LVOT gradient was 140 mm Hg with a mean left atrial pressure of 32 mm Hg. J, Following alcohol septal ablation, the LVOT gradient decreased to 10 mm Hg, in association with a reduction of the mean left atrial pressure to 22 mm Hg. Ao, Ascending aorta; LA, left atrium; LAP, left atrial pressure; LV, left ventricle; LVOT, left ventricular outflow tract; VS, ventricular septum.
KEY POINTS • While percutaneous plication of the MV with MitraClip can be successful in patients with obstructive HCM, residual SAM may occur and lead to significant LVOT obstruction. These patients can be challenging to treat due to the relatively small size of the mitral orifice, which may not permit placement of more than one clip. • In selected cases, alcohol septal ablation can be performed to treat residual LVOT obstruction that becomes evident after percutaneous plication with MitraClip.
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CARDIOMYOPATHY 211
An 82-year-old woman, who was previously treated successfully with percutaneous plication for obstructive hypertrophic cardiomyopathy (HCM) with the MitraClip (Abbott Vascular, Santa Clara, CA), returned 9 months later with severe, drug-refractory symptoms. A, Transesophageal echocardiogram (TEE) shows the previously placed clip in place (arrowhead), and normal laminar flow near its position (arrow). B, Three-dimensional TEE from the left atrium (i.e., surgeon’s view) shows the position of previously placed MitraClip on the A2-P2 segments of the mitral valve (MV) and the associated tissue bridge (arrowhead). However, with further imaging, she had evidence of residual left ventricular outflow tract (LVOT) obstruction due to systolic anterior motion (SAM) of the A1 segment of the MV. C, End-diastolic image on TEE shows patency of the LVOT (arrow) during diastole and no SAM (arrowheads). D, However, SAM is present during systole with flow acceleration (arrowheads). The lateral mitral orifice was too small for additional percutaneous plication, and her mean MV gradient was 4 mm Hg. She therefore underwent alcohol septal ablation. E, Coronary angiography of the left coronary artery shows a large proximal septal perforator (arrowhead). F, Using conventional techniques for alcohol septal ablation, 1.7 mL of desiccated alcohol is injected into this proximal branch of this septal artery for ablation (arrowhead). G, Initial contrast echocardiography demonstrated the distal branch of the septal artery to supply a region of the myocardium too remote from the site of LVOT obstruction (arrow). H, Thus the balloon
210 CARDIOMYOPATHY
catheter was repositioned in the proximal branch, where contrast injection demonstrated an appropriate location for the ablation. I, At baseline, the LVOT gradient was 140 mm Hg with a mean left atrial pressure of 32 mm Hg. J, Following alcohol septal ablation, the LVOT gradient decreased to 10 mm Hg, in association with a reduction of the mean left atrial pressure to 22 mm Hg. Ao, Ascending aorta; LA, left atrium; LAP, left atrial pressure; LV, left ventricle; LVOT, left ventricular outflow tract; VS, ventricular septum.
KEY POINTS • While percutaneous plication of the MV with MitraClip can be successful in patients with obstructive HCM, residual SAM may occur and lead to significant LVOT obstruction. These patients can be challenging to treat due to the relatively small size of the mitral orifice, which may not permit placement of more than one clip. • In selected cases, alcohol septal ablation can be performed to treat residual LVOT obstruction that becomes evident after percutaneous plication with MitraClip.
A
B
C
D
E
F
G
H
I
J
CARDIOMYOPATHY 211