Transcatheter edge-to-edge repair for severe mitral regurgitation in an octogenarian woman with hypertrophic obstructive cardiomyopathy: a case report.

BACKGROUND

Hypertrophic obstructive cardiomyopathy (HOCM) is characterized by asymmetric septal hypertrophy, diastolic dysfunction, and dynamic left ventricular outflow tract (LVOT) obstruction, and is often associated with systolic anterior motion (SAM) of the mitral valve and secondary mitral regurgitation (MR). Established treatments of HOCM include beta-blockers, calcium channel blockers, surgical myectomy, and alcohol septal ablation (ASA); however, elderly patients with a high surgical risk or an unsuitable coronary anatomy have limited therapeutic options. Transcatheter edge-to-edge repair (TEER) has been widely adopted in the treatment of MR, and emerging evidence suggests it could alleviate SAM-related LVOT obstruction. However, clinical research on octogenarians with HOCM is limited.

CASE DESCRIPTION: We report the case of an 83-year-old woman with a history of HOCM, hypertension, and chronic obstructive pulmonary disease, who presented with progressive dyspnea and chest tightness despite optimal medical therapy. Echocardiography revealed severe asymmetric septal hypertrophy, significant SAM, dynamic LVOT obstruction with a peak gradient of 233 mmHg during the Valsalva maneuver, and severe MR originating from the A2-P2 segment. Surgical risk assessment revealed a EuroSCORE II of 9.5% and a Society of Thoracic Surgeons score of 10.2%. Given the absence of suitable septal perforator arteries for ASA and the prohibitive surgical risk, the heart team performed TEER with the MitraClip™ system. A single narrow translational range (NTR) clip was deployed at the A2-P2 position under three-dimensional transesophageal echocardiography guidance, resulting in immediate MR reduction (from severe to mild), SAM resolution, and a decreased resting LVOT gradient to 81 mmHg. Her hemodynamics improved markedly, with left atrial pressure dropping from 55 to 25 mmHg. The patient was discharged with a New York Heart Association classification of I-II. At the 8-month follow-up, she remained asymptomatic, MR was mild, and her LVOT gradient had further decreased to 20 mmHg.

CONCLUSIONS

TEER is a safe and effective therapeutic alternative for elderly HOCM patients with severe MR and SAM-related LVOT obstruction in whom surgical myectomy or ASA is unsuitable. This case showed sustained symptomatic and hemodynamic improvement at the mid-term follow-up, supporting further research on the use of TEER in this high-risk population.