P121 MITRAL VALVE STENOSIS ASSOCIATED WITH LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION: A TERRIBLE COMBINATION WITH A DIFFICULT TREATMENT

Abstract

Abstract Case n. 1 A 77 year–old woman with obstructive hypertrophic cardiomyopathy who had undergone alcohol septal ablation with a reduction in dynamic left ventricular outflow tract (LVOT) gradient from 95 to 65 mmHg was hospitalized for pulmonary oedema. Echocardiography and cardiac catheterization confirmed the presence of obstructive hypertrophic cardiomyopathy with a dynamic gradient of 65 mmHg, and identified a severe calcific mitral stenosis (3D planimetric area= 0,9 cm2). There was severe postcapillary pulmonary hypertension (pulmonary artery mean pressure of 60 mmHg and pulmonary capillary wedge pressure of 26 mmHg). The patient underwent a combined surgical intervention of mitral valve replacement (Epic 27 mm bioprosthesis) and surgical septal myectomy via a mini–thoracotomic approach. After the intervention there were dehiscence and infection of the thoracotomy and right inguinal surgical wounds, septic shock, hyporexia (with marked cachexia), emotional instability and delirium. After 21 days of hospitalization in the ICU, the patient was transferred to a medical department and died seven days later. Case n. 2 A 82 year–old woman with severe mitral stenosis associated with marked left ventricular hypertrophy and LVOT obstruction was admitted for heart failure and worsening renal function. Her comorbidities included diabetic neuropathy and stage 4 chronic kidney disease. Cardiac catheterization excluded significant coronary artery disease; mitral valve area was 1 cm2, and LVOT gradient was 75 mmHg. Pulmonary artery mean pressure was 32 mmHg, pulmonary capillary wedge pressure was 25 mmHg, and right atrial mean pressure was 8 mmHg. She was deemed a high–risk surgical candidate. The patient therefore was treated initially with peritoneal dialysis. However she demonstrated persisting pulmonary congestion. An atrial septostomy inserting a 8–mm Atrial Flow Regulator was subsequently performed, with an immediate reduction of capillary wedge pressure to 18 mmHg. In the following 18 months the patient had no more hospitalizations for heart failure. Conclusion The association between mitral stenosis and LVOT obstruction is associated with elevated capillary wedge pressure and frequent episodes of heart failure. Surgical intervention remains the first therapeutical option. Nevertheless, in older patients, the association between atrial septostomy and peritoneal dialysis may represent a valuable solution, with a lower operative risk.