Alcohol septal ablation as a treatment of left ventricular outflow tract obstruction after mitral valve repair

Abstract

Introduction: Left ventricular outflow tract obstruction (LVOTO) occurrs in 4-5% of patients after mitral valve repair (MVR). If conservative treatment is unsuccessful reoperation is indicated. Case report description: A 72-year old male sought a second opinion consultation for progressive dyspnea after surgical MVR. The procedure was carried out for severe symptomatic mitral regurgitation (NYHA class III dyspnea). Prolaps of mitral valve with rupture of chordae and septal hypertrophy (15 mm) were noted on initial echocardiography. One month after operation, he complained of exertional chest pain, presyncopes and dyspnea of NYHA class III. Echocardiography revealed trace residual regurgitation, basal septal hypertrophy (18 mm) and LVOTO with SAM, peak left ventricular outflow gradient (LVOG) 85 mmHg. The patient refused reoperation. There was no improvement with medical treatment. Alcohol septal ablation (ASA) was suggested as a nonsurgical alternative. ASA was performed by injection of 1.5 ml of alcohol in a suitable septal branch, LVOG decreased immediately. There were no complications, patient was dismissed free of dyspnea. After 2 years of follow-up the patient was still asymptomatic. Echocardiography confirmed good result of ASA: LVOG 13 mmHg at rest, basal septum akinetic and narrowed to 10 mm. Discussion: The report illustrates the dynamic changes of left ventricular geometry occurring after MVR (Fig. 1) and highlights the need for heightened vigilance in patients with basal septal hypertrophy. In this case the patient was successfully treated with ASA. The coincidence of hypertrophic cardiomyopathy wasn't considered preoperatively. ![Figure][1] Figure 1 Conclusion: Based on our experience ASA is a suitable non-surgical therapeutic option in selected patients with septal hypertrophy and LVOTO after MVR. [1]: pending:yes