First Experience With Percutaneous Mitral Valve Plication as Primary Therapy for Symptomatic Obstructive Hypertrophic Cardiomyopathy
Key result
Percutaneous mitral valve plication linked to ~87% lower LVOT gradient and symptom improvement in obstructive HCM.
- P=0.007
- n=6
Why the study?
Few therapeutic options exist for patients with severe heart failure due to obstructive HCM who are at unacceptable surgical risk.
Key Points
- Evaluate the effectiveness of percutaneous mitral valve plication for relieving symptoms in obstructive hypertrophic cardiomyopathy.
- Six patients with severe heart failure symptoms underwent percutaneous mitral valve leaflet plication.
- The procedure aimed to reduce systolic anterior motion and mitral regurgitation using the transcatheter mitral clip system.
- Follow-up echocardiography was conducted after 15 months.
- Intraoperative LVOT gradient decreased significantly from 91 ± 44 mm Hg to 12 ± 6 mm Hg (p = 0.007).
- Mitral regurgitation grade improved from 3.0 ± 0 to 0.8 ± 0.4 (p = 0.0002).
- Symptom improvement to NYHA functional class I or II occurred in all patients over a follow-up of 15 ± 4 months.
Study Design
Type
Case Report (n=6)
PICO
P
Population
6 older adults (mean age 83 years, 83% female) with severe, drug-refractory heart failure due to obstructive HCM who were not optimal candidates for septal myectomy, followed for 15 months.
I
Intervention / Comparator
Percutaneous mitral valve plication
O
Primary Outcome
Intraoperative LVOT gradient (mm Hg), p=0.007
Main Result
Absolute Event Rate: 12% vs 91%
p-value: p=0.007
Limitations
- The significance of persistent elevations of LVOT velocities in some patients requires further study.
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Our series is the first to essentially take a patient who hasn't had anything done to them and try this. That's why we find it very exciting. It's kind of one of these things where people say, why didn't I think of it? That's what people tend to say when we show them our results.”
“I think that's something we're going to need to understand better before we adopt this approach in a more widespread way.”
HVHartzell V. SchaffCardiac surgeon, Mayo Clinic
“It seems critically important to continue follow-up and investigation of the patients with high residual intracavitary velocities to understand whether the Doppler signals are benign and not related to obstruction, or whether these reflect midventricular gradients that can lead to the same symptoms caused by subaortic LVOT gradients.”
Implication
May support percutaneous plication for obstructive HCM symptoms; leaves open efficacy and safety pending larger trials.
Abstract
BACKGROUND: Few therapeutic options exist for patients with severe heart failure due to obstructive hypertrophic cardiomyopathy (HCM) who are at unacceptable surgical risk. We hypothesized that percutaneous plication of the mitral valve could reduce left ventricular outflow tract (LVOT) obstruction and associated mitral regurgitation, thereby leading to amelioration of heart failure symptoms. OBJECTIVES: This study sought to evaluate the potential effectiveness of percutaneous mitral valve plication as a therapy for patients with symptomatic, obstructive HCM. METHODS: Six patients (age 83 ± 8 years; 5 women), judged as not optimal candidates for septal myectomy, were referred for management of severe, drug-refractory heart failure symptoms due to obstructive HCM (New York Heart Association functional class III). Each underwent percutaneous mitral valve leaflet plication to reduce systolic anterior motion (SAM) and mitral regurgitation using the transcatheter mitral clip system. RESULTS: The procedure was completed in 5 patients with placement of a single clip at the A2-P2 segments of the mitral valve. One other patient experienced cardiac tamponade, leading to termination of the procedure. Among the 5 treated patients, percutaneous plication with the eliminated SAM and consequently decreased the intraoperative LVOT gradient (91 ± 44 mm Hg to 12 ± 6 mm Hg; p = 0.007), left atrial pressure (29 ± 11 mm Hg to 20 ± 8 mm Hg; p = 0.06), and mitral regurgitation grade (3.0 ± 0 vs. 0.8 ± 0.4; p = 0.0002) associated with improved cardiac output (in n = 4; 3.0 ± 0.6 l/min to 4.3 ± 1.2 l/min; p = 0.03). Over follow-up of 15 ± 4 months, symptom improvement to New York Heart Association functional class I or II occurred in all patients. Follow-up echocardiography after 15 ± 4 months demonstrated continued absence of SAM and significant reduction in mitral regurgitation, although high systolic LVOT velocities (i.e., >4 m/s) were evident in 3 of the 5 treated patients. CONCLUSIONS: This is a report of percutaneous mitral valve plication as a primary therapy in the management of severely symptomatic, obstructive HCM patients. This initial experience suggests that percutaneous mitral valve plication may be effective for symptom relief in such patients via reduction of SAM and mitral regurgitation. The significance of persistent elevations of LVOT velocities in some patients requires further study.
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Cite This Study
Sorajja et al. (2016) conducted a case report in symptomatic obstructive hypertrophic cardiomyopathy (n=6). Percutaneous mitral valve plication was evaluated on Intraoperative LVOT gradient (mm Hg) (p=0.007). Percutaneous mitral valve plication in 5 treated patients with obstructive HCM decreased the intraoperative LVOT gradient from 91 to 12 mm Hg and improved symptoms.