First-in-Man MitraClip Implantation to Treat Late Postoperative Systolic Anterior Motion

A 52-year-old man underwent surgical mitral repair for P2 flail. A conventional Carpentier technique was used (quadrangular resection+sliding plasty and annuloplasty with a 35-mm flexible band). Predischarge echocardiography showed no residual MR and no systolic anterior motion (SAM). One year after surgery, the patient came to our attention complaining dyspnoea on effort (New York Heart Association III). Rest echocardiography showed absence of recurrent MR, but evidence of SAM with mild left ventricular outflow tract (LVOT) obstruction. Exercise echocardiography revealed a significant SAM with severe LVOT obstruction (Figure 1; Movies I–III in the Data Supplement). An induced pressure gradient of 144 mm Hg and a dynamic flow acceleration with late systolic peak velocity were observed across the LVOT with concomitant moderate MR and mild pulmonary hypertension (systolic pulmonary pressure, 40 mm Hg; Figure 1). A pharmacological approach was attempted first (atenolol, 100 mg QID; diltiazem 180 mg QID) without clinical improvements and changes in SAM and LVOT obstruction. Therefore, an interventional strategy was considered. A MitraClip procedure was planned to correct the SAM. Adrenaline infusion was used to induce SAM. After ineffective attempts to place the clip in the central …