Abstract 4142124: Transcatheter mitral edge-to-edge repair in a patient with symptomatic SAM and LVOT obstruction following surgical robotic mitral valve repair

Background: Persistent systolic anterior motion (SAM) following robotic mitral valve repair can lead to symptomatic left ventricular outflow tract (LVOT) obstruction. Percutaneous mitral valve edge-to-edge repair using MitraClip to manage LVOT obstruction from SAM following mitral valve repair has been rarely reported. Case: A 64-year-old male with history of mitral regurgitation from posterior leaflet prolapse who underwent robotic mitral valve repair with posterior leaflet butterfly resection and 38 mm Cosgrove annuloplasty band presented with progressive dyspnea with exertion and fatigue three years later. Transesophogeal echocardiogram (TEE) revealed 3+ mitral regurgitation (MR) (mean mitral valve pressure gradient 4.2 mmHg, heart rate 88 bpm) and SAM of the mitral valve with LVOT obstruction (resting gradient of 78 mmHg). He underwent a left heart catheterization to accurately measure the LVOT gradient with Dobutamine infusion. Baseline LVOT gradient was 20 mmHg that increased to 40 mmHg, 60 mmHg, and 140 mmHg with Stage 1 (5 mcg/kg/min), Stage 2 (10 mcg/kg/min), and Stage 3 (20 mcg/kg/min) of Dobutamine infusion, respectively. Decision-Making: Given his symptomatic LVOT obstruction from SAM, he was initially referred to CT Surgery for consideration of mitral valve replacement, however, given his desire to avoid long-term anticoagulation and risk of redo surgery, he was evaluated for percutaneous management. He underwent TEE guided transcatheter mitral edge-to-edge repair using a single XTW MitraClip with capture of the A2 and P2 leaflets. Post-procedural transthoracic echocardiogram (TTE) revealed trace MR and no SAM or LVOT obstruction with a resting LVOT gradient of 8 mmHg. At outpatient follow up, his shortness of breath and fatigue had significantly improved. Conclusion: Mitral valve edge-to-edge repair using MitraClip can be a safe and effective management option for patients who develop persistent SAM resulting in symptomatic LVOT obstruction following mitral valve repair.