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

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

Hang Wu1#, Sijia Wang1,2,3#, Yi Wang2,3, Qinglan Shu2,3, Cong Lu4, Jie Zeng4

1School of Medicine, University of Electronic Science and Technology of China, Chengdu, China; 2Department of Cardiovascular Ultrasound & Noninvasive Cardiology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China; 3Ultrasound Medicine and Computational Cardiology Key Laboratory of Sichuan Province, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China; 4Department of Cardiology and Center of Structure Heart Disease, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China

Contributions: (I) Conception and design: H Wu, S Wang; (II) Administrative support: Y Wang, J Zeng; (III) Provision of study materials or patients: C Lu, Q Shu; (IV) Collection and assembly of data: H Wu, S Wang, J Zeng; (V) Data analysis and interpretation: H Wu, S Wang, Y Wang; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

#These authors contributed equally to this work.

Correspondence to: Jie Zeng, MD. Department of Cardiology and Center of Structure Heart Disease, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, 32# W. Sec 2, 1st Ring Rd, Chengdu 610072, China. Email: jiezeng999@sina.com.

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.

Keywords: Transcatheter edge-to-edge repair (TEER); systolic anterior motion (SAM); hypertrophic obstructive cardiomyopathy (HOCM); mitral regurgitation (MR); case report

Submitted Feb 17, 2025. Accepted for publication Jul 24, 2025. Published online Oct 16, 2025.

doi: 10.21037/qims-2025-400

Video 1 Two-dimensional echocardiographic video of significant SAM before TEER. SAM, systolic anterior motion; TEER, transcatheter edge-to-edge repair.
Video 2 Severe mitral regurgitation due to SAM before TEER. SAM, systolic anterior motion; TEER, transcatheter edge-to-edge repair.
Video 3 Mild mitral regurgitation at the 8-month follow-up after the operation.

Introduction

Hypertrophic cardiomyopathy (HCM) is a common autosomal dominant genetic disorder, affecting approximately 1 in 200–500 individuals, and is characterized by asymmetric ventricular hypertrophy and diastolic dysfunction (1). A subset of patients will develop dynamic left ventricular outflow tract (LVOT) obstruction, often accompanied by symptoms such as dyspnea, chest tightness, or syncope. The obstruction is typically due to a combination of septal hypertrophy, congenital mitral valve anomalies, and systolic anterior motion (SAM) of the mitral valve.

Beta-blockers remain the first-line pharmacological treatment for hypertrophic obstructive cardiomyopathy (HOCM), but a significant proportion of patients do not achieve complete symptom relief (2). Alternative therapies include mavacamten (a cardiac myosin inhibitor recently approved by the Chinese National Medical Products Administration), surgical septal myectomy, and alcohol septal ablation (ASA). While these therapeutic approaches have exhibited satisfactory clinical efficacy, they also carry procedural risks such as arrhythmia, atrioventricular block, and septal perforation (3). For patients considered unsuitable for surgery or ASA, newer treatment strategies are under investigation, such as ultrasound-guided percutaneous intramyocardial septal radiofrequency ablation (PIMSRA), also known as the Liwen procedure.

Although relieving LVOT obstruction remains the primary therapeutic goal, attention has increasingly turned to the mitral valve itself, especially in patients with SAM-induced mitral regurgitation (MR). Transcatheter mitral valve repair using edge-to-edge techniques such as the MitraClip™ system, which is a minimally invasive medical device developed by Abbott (Santa Clara, CA, USA), has shown promising results in high-risk patients with functional MR. Recent studies suggest that transcatheter edge-to-edge repair (TEER) may also play a role in alleviating SAM and MR in HOCM patients with dynamic LVOT obstruction (4,5).

This article presents a unique case in which TEER was used to treat severe MR and LVOT obstruction in an elderly HOCM patient with a high surgical risk. A brief review of the relevant literature is also provided. We present this case in accordance with the CARE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-400/rc).

Case presentation

The patient was an 83-year-old female, who had been diagnosed with HOCM several years before admission, and had been on long-term therapy with metoprolol succinate (47.5 mg daily and diltiazem 90 mg twice daily). Despite the pharmacological treatment, she continued to experience symptoms of chest tightness and dyspnea. She also had a 5-year history of hypertension and a 10-year history of chronic obstructive pulmonary disease. She had a EuroSCORE II of 9.5%, and a Society of Thoracic Surgeons score of 10.2%, indicating a high surgical risk. Over the past 3 years, her cardiac function had progressively deteriorated from New York Heart Association (NYHA) class II to class III–IV, and her symptoms were present even at rest.

Twelve-lead electrocardiogram showed ST-T segment depression and signs of left ventricular hypertrophy. Transthoracic echocardiography (TTE) showed asymmetric septal hypertrophy with a maximal wall thickness of 16 mm at the LVOT level. Transesophageal echocardiography (TEE) revealed significant SAM of the anterior mitral leaflet (Figure 1, Video 1), causing dynamic LVOT obstruction (Figures 2,3) and severe MR (Figure 2, Video 2). On Valsalva maneuver, the LVOT pressure gradient reached 233 mmHg. Her left atrium was dilated and pulmonary artery systolic pressure was elevated. Reversed systolic wave was observed in the pulmonary vein flow (Figure 4). No abnormal muscle bundles were observed on imaging, including TEE and TTE.

Figure 1 Transesophageal echocardiography showed significant systolic anterior motion (as indicated by the red arrow). LA, left atrium; LV, left ventricle.
Figure 2 Transesophageal echocardiography showed severe mitral regurgitation (as indicated by the red arrow) and turbulent flow in the LVOT (as indicated by the green arrow). AO, aorta; LA, left atrium; LV, left ventricle; LVOT, left ventricular outflow tract; RV, right ventricle.
Figure 3 Transthoracic echocardiography showed blood flow spectrum of LVOT obstruction with increased LVOT blood flow velocity. The red arrow indicates the peak LVOT velocity during left ventricular systole. LVOT, left ventricular outflow tract.
Figure 4 Transesophageal echocardiography showed reverse systolic wave (as indicated by red arrows) in the right superior pulmonary vein.

Laboratory tests showed normal cardiac troponin levels and elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) (1,600 pg/mL). Coronary computed tomography angiography revealed no significant coronary stenosis, and no suitable septal perforator branches for ASA were present. Based on a multidisciplinary heart team discussion, the patient was considered unsuitable for surgery or ASA.

To relieve MR and dynamic obstruction, the team opted for TEER with the MitraClip™ system. Pre-procedural TEE confirmed moderate to severe MR, a mitral valve effective regurgitant orifice area of 0.31 cm2, and a regurgitant volume of 78 mL. The mitral valve area was 3.1 cm2 (planimetrically measured in multiple views), with leaflet lengths of 24 mm (anterior) and 11 mm (posterior). The diastolic mean trans-mitral gradient was 1 mmHg. The regurgitant jet originated from the A2–P2 segment with reversed pulmonary vein flow.

Procedure

The procedure was performed under general anesthesia. After successful transseptal puncture, a MitraClip™ narrow translational range (NTR) device was implanted at the A2–P2 segment under real-time 3D-TEE guidance.

Following implantation, TEE revealed significant improvement with only mild residual MR. The residual mitral valve orifice area was 1.6 cm2, and the mean diastolic trans-mitral pressure gradient increased to 4 mmHg. The LVOT gradient decreased to 81 mmHg. Invasive hemodynamic monitoring showed left atrial pressure dropped significantly from 55 mmHg pre-procedure to 25 mmHg post-procedure. Pulmonary vein flow spectrum normalized (Figure 5).

Figure 5 Transesophageal echocardiography showed that immediately post-intervention, the pulmonary vein flow spectrum had returned to normal (as indicated by red arrows).

Immediately post-procedure, TEE demonstrated complete resolution of SAM and no evidence of device-induced LVOT obstruction. The implanted clip remained stable and was not displaced toward the LVOT, ruling out a significant Venturi effect.

The patient tolerated the procedure well and was discharged on postoperative day 7 with a NYHA classification of I–II. Before discharge, TTE showed a preserved left ventricular ejection fraction of 77%, a mitral E-wave peak velocity of 1.24 m/s, a trans-mitral mean pressure gradient of 3.5 mmHg, and her resting LVOT peak gradient had decreased from 144 to 34 mmHg.

At the 8-month follow-up, the patient remained symptomatically improved. The LVOT gradient had further decreased to 20 mmHg (Figure 6), MR remained mild (Figure 7, Video 3), and the mitral clip was clearly visualized on two-dimensional TEE (Figure 8). Her NT-proBNP level was 1,136 pg/mL, and no recurrence of dyspnea or chest pain was reported (Table 1). The patient reported significant improvement in her dyspnea symptoms.

Figure 6 Transthoracic echocardiography showed that at 8 months post-intervention, the LVOT pressure gradient was further reduced (as indicated by the red arrow). LVOT, left ventricular outflow tract.
Figure 7 Transthoracic echocardiography showed that at 8 months post-intervention, there was only mild mitral regurgitation (as indicated by the red arrow). AO, aorta; LA, left atrium; LV, left ventricle; RV, right ventricle.
Figure 8 Two-dimensional echocardiographic imaging provided a clear visualization of the clip (as indicated by the red arrow). LA, left atrium; LV, left ventricle.

Table 1

Hemodynamic and structural improvements over the course of treatment

Assessment by echocardiography Baseline Postoperative follow-up
Immediate Day 3 Month 8
Ejection fraction (%) 69 68 77 81
Left atrial systolic diameter (mm) 44 45 42 47
Left ventricular diastolic diameter (mm) 46 39 37 38
Left ventricular outflow tract peak gradient (mmHg) 146 81 34 21
Left ventricular outflow tract peak gradient (Valsalva) (mmHg) 233 – 42 38
Interventricular septum diastolic thickness (mm) 15 17 15 16
Mitral valve area (cm2) 3.1 1.6 2.0 2.8
Mitral mean gradient (mmHg) 2.0 4 3.5 2.1
Mitral peak velocity (m/s) 1.3 1.4 1.24 0.87
Effective regurgitant orifice area, effective regurgitant orifice area (cm2) 0.32 0.17 0.07 0.08
Regurgitant volume (mL) 71 40 32 33
Mitral regurgitation grade (I–IV) IV+† II+‡ I II
Pulmonary arterial pressure (mmHg) 48 45 46 32
New York Heart Association classification (I–IV) III – I I
Laboratory testing: N-terminal pro-B-type natriuretic peptide 1,600 1,400 1,708 1,136

†, IV+ indicates that the patient had severe mitral regurgitation before the procedure. ‡, II+ indicates that the patient had mild-to-moderate mitral regurgitation immediately after the procedure.

Ethical consideration

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Medical Research Ethics Committee of Sichuan Provincial People’s Hospital. Written informed consent was obtained from the patient for the publication of this case report, accompanying images and videos. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

HCM is a genetically determined cardiac disorder with an estimated prevalence of 1:200 to 1:500 in the general population (6). It is characterized by asymmetric septal hypertrophy, diastolic dysfunction, and, in a subset of patients, dynamic LVOT obstruction (7-9).

Mitral valve abnormalities frequently coexist in patients with HOCM, including anterior leaflet elongation, increased leaflet surface area, and anteriorly displaced papillary muscles (10). These structural abnormalities contribute to SAM, exacerbating LVOT obstruction and resulting in secondary MR (10,11-13).

First-line management of HOCM includes beta-blockers and calcium channel blockers, which reduce contractility and improve diastolic filling (14-17). Pharmacologic options include mavacamten, a selective inhibitor of cardiac myosin. The patient sought medical attention in 2022 when mavacamten was not yet commercially available in China. Additionally, long-term safety data on the use of mavacamten in elderly populations is lacking. The patient was considered unsuitable for surgical myectomy due to her age, comorbidities, and elevated procedural risk scores. Additionally, there were no suitable septal perforator branches for ASA. Thus, the patient had a high-risk phenotype and limited therapeutic options.

M-TEER has emerged as a novel technique for treating MR in patients with dynamic LVOT obstruction and SAM, particularly when conventional therapies are contraindicated (18,19). Since the first report by Schäfer et al. (20) in 2014, multiple case series have shown the efficacy of M-TEER in relieving obstruction and MR in HOCM patients (21-25).

The MitraClip and PASCAL (Edwards Lifesciences, Irvine, CA, USA) systems, which have a unique elongation feature aiding chordal navigation, are TEER devices designed for the treatment of MR. Globally, both systems have shown excellent safety and efficacy in appropriately selected patients (26). In China, the MitraClip system has been used as the primary device for TEER since its introduction, and its clinical use in tertiary cardiovascular centers has continued to increase. The PASCAL system has gained recognition globally for its unique features such as a broader spacer, but its use in China remains limited due to delayed regulatory approval and its limited availability. As a result, most current TEER procedures in China employ the MitraClip system. In this case, the anterior mitral leaflet measured 24 mm and the posterior leaflet measured 11 mm, with regurgitation originating from the A2–P2 segment. Based on pre-procedural imaging, a single NTR clip was chosen to approximate this region. This approach was supported by literature indicating that central clip placement effectively reduces both SAM and MR by altering leaflet coaptation geometry and posteriorly displacing the mitral coaptation point (21,27).

The mitral valve area remained adequate (1.6 cm2 post-procedure), and the trans-mitral gradients were acceptable. This is essential because excessive reduction in the mitral valve area may lead to functional mitral stenosis and worsening symptoms. Had the mitral valve effective orifice area been larger and the leaflet length more redundant, an XTR clip would have been preferred.

There was no echocardiographic evidence of anomalous muscle bundles in this patient. When present, such structures can worsen LVOT obstruction and require additional surgical or imaging considerations.

Several mechanisms could explain the alleviation of the LVOT obstruction in this case, including: (I) SAM elimination via anterior leaflet excursion limitation; (II) MR reduction by leaflet coaptation improvement; and (III) the modification of LVOT hemodynamics via altered mitral valve geometry. These effects may be especially beneficial in octogenarian patients in whom invasive septal reduction is usually high risk.

Our experience aligns with previously published outcomes of significant reductions in LVOT gradients (from 233 to 20 mmHg), SAM resolution, and improved NYHA class. No significant arrhythmias or device-related complications occurred during the follow-up period (20-24).

Limitations

This case report described a single patient. Further clinical experience is needed to guide the treatment of this patient group, and large-scale controlled studies need to be conducted in the future to further validate our findings in the HOCM population. With the recent approval of mavacamten in China, research also needs to be conducted to determine whether the combined use of this pharmacological agent and TEER provides additional clinical benefits to patients.

Conclusions

TEER represents a promising therapeutic option for octogenarian patients with HOCM in whom surgical myectomy or ASA is unsuitable. In this case, TEER effectively eliminated SAM, significantly reduced MR, and alleviated LVOT obstruction. At the 8-month follow-up, the patient demonstrated sustained symptomatic and hemodynamic improvement without complications. Generally, TEER may be most beneficial for patients with the following features: (I) an advanced age and a high surgical risk; (II) persistent symptoms despite maximal medical therapy; (III) severe MR and SAM-related LVOT obstruction; and (IV) an unsuitable anatomy for septal ablation.

Our findings are encouraging; however, further studies with larger patient cohorts and longer follow-up periods are required to confirm the long-term safety and efficacy of this treatment.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-400/rc

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-400/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Medical Research Ethics Committee of Sichuan Provincial People’s Hospital. Written informed consent was obtained from the patient for the publication of this case report, accompanying images and videos. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Wu H, Wang S, Wang Y, Shu Q, Lu C, Zeng J. Transcatheter edge-to-edge repair for severe mitral regurgitation in an octogenarian woman with hypertrophic obstructive cardiomyopathy: a case report. Quant Imaging Med Surg 2025;15(11):11621-11629. doi: 10.21037/qims-2025-400

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