Mitral Transcatheter Edge-to-Edge Repair in Non-Surgical Candidates with Hypertrophic Obstructive Cardiomyopathy: Clip It, or Ablate It?

Figures

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  Figure 1. Different pathomechanisms of MR in patients with HOCM. The mitral valve, including the mitral annulus, chordae tendineae, papillary muscles, and leaflets, shows changes in patients with HCM compared with the normal population. In particular, leaflet redundancy arises from excess tissue and leaflet elongation. Degeneration of the leaflets with signs of calcification and prolapse can also be documented. Another interesting finding in HCM patients is elongation, hypertrophy, and apical displacement of the papillary muscles. Mitral annular dilatation, calcification, or pathological angulation are also noted. These alterations of the mitral valve apparatus, in combination with LVOT hypertrophy and the overall shape, as well as the mitral–septal angle, are important factors related to the exacerbation of SAM and MR severity. HOCM: hypertrophic obstructive cardiomyopathy, LVOT: left ventricular outflow tract, MR: mitral regurgitation, SAM: systolic anterior motion.

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  Figure 2. M-TEER versus TASH in poor surgical HOCM candidates despite optimal medical treatment. M-TEER: mitral transcatheter edge to edge repair, MR: mitral regurgitation, SAM: systolic anterior motion, TASH: transcoronary ablation of septal hypertrophy.

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  Figure 3. Percutaneous approach of non-surgical candidates with obstructive hypertrophic cardiomyopathy and concomitant mitral regurgitation.

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  Figure 4. Hypertrophic obstructive cardiomyopathy with obstructive phenomena in the left ventricular outflow tract, with a peak velocity (Vmax) of about 7 m/s and systolic anterior motion of the mitral valve, resulting in an eccentric mitral regurgitation jet extending to the roof of the left atrium. (left and right upper, left bottom). A suitable first septal branch (white arrow) for TASH (bottom-middle). An increased rest gradient documented invasively (right bottom). (Courtesy of Ulrich Schäfer).

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  Figure 5. Successful TASH procedure with alcohol injection targeted at the first septal branch (white arrow, top-middle), after excluding the second and third septal branches as unsuitable, resulting in a substantial reduction of the LVOT gradient while the MR remained moderate to severe (left and right upper). In the same procedure, a single NT MitraClip (bottom-middle) was implanted in the A2/P2 segment, achieving near elimination of the MR and a residual LVOT gradient (left and right bottom). (Courtesy of Ulrich Schäfer). LVOT: left ventricular outflow tract, MR: mitral regurgitation, TASH: transcoronary ablation of septal hypertrophy.