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Paradoxical Increase in Left Ventricular Outflow Tract Gradient in a Patient Undergoing Mitral Valve Repair and

Devika Poduval1, Thushara Madathil1, P Nagarjuna1

  • 1Departments of Cardiac Anaesthesia, Amrita Institute of Medical Sciences, Kochi, Kerala, India.

Annals of Cardiac Anaesthesia
|July 9, 2025
PubMed

Insights

Septal myectomy may not always reduce the left ventricular outflow tract (LVOT) gradient in hypertrophic cardiomyopathy (HCM) patients with mitral regurgitation. Chordal rupture and mitral valve repair can complicate gradient assessment, impacting treatment decisions.

Area of Science:

  • Cardiology
  • Cardiac Surgery
  • Echocardiography

Background:

  • Obstructive hypertrophic cardiomyopathy (HCM) often requires septal myectomy for symptomatic relief.
  • Doppler-derived gradients are crucial for diagnosis but can be affected by flow dynamics and anatomical changes.
  • Chordal rupture and mitral regurgitation can complicate the assessment of left ventricular outflow tract (LVOT) gradients.

Purpose of the Study:

  • To discuss the diagnostic challenges and treatment dilemmas in patients with obstructive HCM, severe mitral regurgitation, and low LVOT gradient.
  • To analyze a case where septal myectomy did not resolve the LVOT gradient after mitral valve repair.

Main Methods:

  • Review of clinical presentation and echocardiographic findings in a patient with obstructive HCM.
  • Analysis of hemodynamic changes and gradient assessment before and after surgical intervention.
  • Discussion of the interplay between septal hypertrophy, mitral valve pathology, and LVOT flow dynamics.

Main Results:

  • A patient with severe septal hypertrophy and mitral regurgitation experienced an unexpected increase in LVOT gradient post-myectomy and mitral valve repair.
  • Chordal rupture and posterior leaflet flail contributed to altered LVOT geometry and flow patterns.
  • The presence of severe mitral regurgitation and specific anatomical changes masked the true LVOT gradient.

Conclusions:

  • Septal myectomy's efficacy in reducing LVOT gradient can be influenced by concurrent mitral valve disease and anatomical complexities.
  • Careful echocardiographic assessment is vital in cases of low LVOT gradient with severe mitral regurgitation and evidence of chordal rupture.
  • The decision for septal myectomy should be individualized, considering the potential impact of mitral valve repair on LVOT flow and gradient.

Keywords:
HCMMRSAMhypertrophic cardiomyopathymitral regurgitationseptal myectomysystolic anterior motion of mitral valvetransesophageal echocardiography

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