Meningioma Resection in a Patient with High-Risk Obstructive Hypertrophic Cardiomyopathy: Preoperative Mavacamten Optimization and Multidisciplinary Management

Abstract Background The clinical presentation of meningioma combined with obstructive hypertrophic cardiomyopathy (HOCM) is extremely rare, and perioperative management is exceptionally challenging. High-risk HOCM without optimization is generally regarded as an absolute contraindication for craniotomy, and there is a profound lack of established experience regarding its successful management. Case presentation: A 50-year-old man presented with headache and dizziness. Magnetic resonance imaging showed a large anterior skull base meningioma abutting the internal carotid and anterior cerebral arteries. Preoperative cardiac evaluation diagnosed obstructive hypertrophic cardiomyopathy with a resting left ventricular outflow tract gradient of 133 mm Hg and a right ventricular ejection fraction of 28%. After multidisciplinary team discussion, mavacamten was started. The gradient fell to 79 mm Hg after 5 days. The tumor was then completely resected under goal-directed hemodynamic management. The perioperative course was uneventful. Postoperative brain swelling resolved with conservative treatment. At 1-month follow-up, the patient had recovered well without cardiac or surgical complications. Conclusions Unoptimized obstructive hypertrophic cardiomyopathy is an absolute contraindication to craniotomy. However, selected patients whose hemodynamics are stabilized by medical therapy can undergo surgery safely within a multidisciplinary framework. Maintaining preload, avoiding tachycardia, and preserving afterload are essential for perioperative safety.