Figure legends:
Figure 1. Baseline transthoracic echocardiography and pressure wire
findings.
Transthoracic echocardiography revealed exacerbated left ventricular
outflow tract (LVOT) obstruction and severe mitral regurgitation (MR)
with systolic anterior motion (SAM) after surgical AVR (Figure 1a and
1b).
Invasive pressure wire shows real-time pressure gradients between left
ventricular (green line) and aortic (red line) pressure (Figure 1c).
Pressure gradient LVOT was 100 mmHg. These gradients did not differ
during pressure wire retraction (Figure 1d and e).
Figure 2. Percutaneous transluminal septal myocardial ablation.
The first to third septal perforator arteries were accessed for ablation
(Figure 2a). Contrast agent was selectively injected distal to occlusive
balloon, and its effects were monitored by simultaneous transthoracic
echocardiography. Gradient in LVOT was reduced to from 229 to 20 mmHg
immediately after alcohol was injected, without evident malignant
arrhythmias (lower panels). Final coronary angiography after alcohol
injection shows occluded target septal arteries and no injury to LAD
(Figure 2b). Echocardiography at one month of follow-up shows obvious
resolution of mitral regurgitation, SAM and outflow tract obstruction
(lower right panels).
Figure 3. Post-procedural progress.
Patient remained free of malignant arrhythmias for three days in
coronary care unit. She was discharged from hospital on post-procedure
day 35 with pleural effusion and laboratory data improvement.