Intraoperative imaging of a combined minimally invasive therapy for aortic valve stenosis with hypertrophic obstructive cardiomyopathy - case report

Q: What preoperative findings established the combined pathology?

Severe aortic valve stenosis was confirmed with a peak transvalvular gradient of 111 mmHg, while hypertrophic obstructive cardiomyopathy was identified by septal thickness of 19 mm and an LVOT gradient of 61 mmHg.

Q: How was intraoperative imaging used during the septal myectomy?

Real-time transesophageal echocardiography provided a localization/trajectory and guided a measurement–decision loop, supporting resection planning and reassessment after each pass.

Q: What were the procedural goals before completing myectomy?

The target was an LVOT gradient below 30 mmHg at rest and below 50 mmHg with provocation, with MR no greater than 1+. Additional targeted resection was performed if residual obstruction persisted.

Sep 30, 2026

Uploaded by Olivia Brown

A 65-year-old woman with dizziness and prior stroke underwent multimodal evaluation for severe aortic valve stenosis and hypertrophic obstructive cardiomyopathy. Echocardiography, CT, and MRI showed a peak transvalvular gradient of 111 mmHg and prominent dynamic LVOT obstruction, with septal thickness 19 mm and LVOT gradient 61 mmHg; CT quantified annular geometry for planning. The perioperative risk was driven by COPD, post-stroke frailty, and insulin-dependent diabetes. The report details intraoperative TEE-guided transapical beating-heart septal myectomy and subsequent TAVI, with marked gradient reduction and improvement at follow-up.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages4

Reading Time10 min

AccessFree to download

Case presentation and baseline imaging

Perioperative risk assessment

Combined minimally invasive therapy workflow

TEE-guided transapical beating-heart septal myectomy

Safety boundaries and procedural endpoints

Transition to TAVI and outcomes

Cardiovascular Intervention and Therapeutics (2026) 41:203–206 [https://doi.org/10.1007/s12928-025-01](https://doi.org/10.1007/s12928-025-01)194-7 Intraoperative imaging of a combined minimally invasive therapy for aortic valve stenosis with hypertrophic obstructive cardiomyopathy: a case report Xiaoxue Zhang1 · Shiliang Li1 · Zijun Chen3 · Yi feng2 · Xiang Wei1 · Cai Cheng2 Received: 5 February 2025 / Accepted: 8 September 2025 / Published online: 26 September 2025 © The Author(s) 2025 A 65-year-old woman presented with dizziness and a history of stroke. Echocardiography, CT, and MRI revealed severe aortic valve stenosis (AS) with a peak instantaneous transvalvular gradient of 111 mmHg on TEE (Fig. 1A), and demonstrated aortic annular cross-sectional areas of 403.8 and 386.5 mm2 in systole and diastole, respectively (Fig. 1B) . Further evaluation identified hypertrophic obstructive cardiomyopathy (HOCM), with a septal thickness of 19 mm and a left ventricular outflow tract (LVOT) gradient of 61 mmHg (Fig. 1C) . CT angiography confirmed a mean systolic annular diameter of 23.0 mm (Fig. 1B) . Perioperative risk (EuroSCORE II 7.99%) was driven primarily by COPD, residual post-stroke frailty with limited mobility, and insulin-dependent diabetes; the patient was NYHA class III with LVEF 55% . With advances in less-invasive structural interventions, transapical beating-heart septal myectomy (TA-BSM, details in Fig. 2) [1] has emerged as a complementary option for patients with concomitant HOCM and AS undergoing transcatheter aortic valve implantation (TAVI) . The beatingheart myectomy device (BMD, Wei-Xin-Tan Corp, China) is manufactured in models defined by the resection-window Xiaoxue Zhang and Shiliang Li are co-first authors. * Xiang Wei [xiangwee@126.com](xiangwee@126.com) * Cai Cheng [cai.cheng@hotmail.com](cai.cheng@hotmail.com) 1 Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei, China 2 Division of Cardiothoracic and Vascular Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang, China 3 Wuhan Taikang Tongji Hospital, Wuhan 430050, Hubei, China length and the sleeve-tube diameter (length/diameter, mm): 11/30, 11/40, 13/30, and 13/40 . In this case, an 11/30-mm device was used. In the published first-in-human series [1], the extent of septal resection was reported by weight (not by area), with a median resected myocardial weight of 4.1 g (IQR 2.5–6.0 g; range 1.0–17.9 g) . The resected myocardial weight in our case was 3.9 g. After induction of general anesthesia and left anterolateral mini-thoracotomy, two concentric apical purse-strings are placed; the apex is punctured and dilated to introduce the BMD. Real-time TEE guides a closed view → measurement → decision loop: Localization/trajectory: Mid-esophageal long-axis (~ 110–130°) aligns the LVOT–AV–IVS axis and confirmsa 5–10 mm safety margin below the aortic annulus; transgastric basal short axis refines the BMD cutting-window orientation and apposition to the most hypertrophied septum. First resection + reassessment: Initial myectomy in the basal anterior septum, centered 5–10 mm sub-annular; immediate TEE reassessment documents LVOT peak instantaneous/mean gradients, SAM, MR, and septal thickness. Sequential passes: Second pass rotated ~ 60–120°clockwise and slightly more basal to create a shallow, parallel groove channel; if needed, extend toward the mid-septum under long-axis guidance with gentle apex-to-base traction toward the apex before further cuts. Dual endpoints: Procedural target: LVOT gradient < 30 mmHg at rest and < 50 mmHg with provocation, with MR ≤ 1 + ; if isoproterenol or Valsalva reveals residual obstruction, perform targeted additional resection until thresholds are met. Safety boundaries: Avoid over-resection near the basal posterior septum (conduction system) to reduce postoperative LBBB risk; mainta

FAQs

What preoperative findings established the combined pathology?

Severe aortic valve stenosis was confirmed with a peak transvalvular gradient of 111 mmHg, while hypertrophic obstructive cardiomyopathy was identified by septal thickness of 19 mm and an LVOT gradient of 61 mmHg.

How was intraoperative imaging used during the septal myectomy?

Real-time transesophageal echocardiography provided a localization/trajectory and guided a measurement–decision loop, supporting resection planning and reassessment after each pass.

What were the procedural goals before completing myectomy?

The target was an LVOT gradient below 30 mmHg at rest and below 50 mmHg with provocation, with MR no greater than 1+. Additional targeted resection was performed if residual obstruction persisted.

Sep 30, 2026

Uploaded by Olivia Brown