title: Mitral stenosis and hypertrophic obstructive cardiomyopathy: An unusual combination.
abstract: OBJECTIVE
  Systolic anterior motion of mitral valve (MV) leaflets is a main pathophysiologic feature of left ventricular outflow tract (LVOT) obstruction in hypertrophic obstructive cardiomyopathy. Thus, restricted leaflet motion that occurs with MV stenosis might be expected to minimize outflow tract obstruction related to systolic anterior motion.
  
  
  METHODS
  From January 1993 through February 2015, we performed MV replacement and septal myectomy in 12 patients with mitral stenosis and hypertrophic obstructive cardiomyopathy at Mayo Clinic Hospital in Rochester, Minn. Preoperative data, echocardiographic images, operative records, and postoperative outcomes were reviewed.
  
  
  RESULTS
  Mean (standard deviation) age was 70 (7.6) years. Preoperative mean (standard deviation) maximal LVOT pressure gradient was 75.0 (35.0) mm Hg; MV gradient was 13.7 (2.8) mm Hg. From echocardiographic images, 4 mechanisms of outflow tract obstruction were identified: systolic anterior motion without severe limitation in MV leaflet excursion, severe limitation in MV leaflet mobility with systolic anterior motion at the tip of the MV anterior leaflet, septal encroachment toward the LVOT, and MV displacement toward the LVOT by calcification. Mitral valve replacement and extended septal myectomy relieved outflow gradients in all patients, with no death or serious morbidity.
  
  
  CONCLUSIONS
  Patients with mitral stenosis and hypertrophic obstructive cardiomyopathy have multiple LVOT obstruction mechanisms, and MV replacement may not be adequate treatment. We favor septal myectomy and MV replacement in this complex subset of hypertrophic obstructive cardiomyopathy.
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Joonhwa
authors.initials: J
authors.lastname: Hong
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn. Electronic address: schaff@mayo.edu.
authors.forename: Hartzell V
authors.initials: HV
authors.lastname: Schaff
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn.
authors.forename: Steve R
authors.initials: SR
authors.lastname: Ommen
authors.affiliation: Division of Cardiovascular and Thoracic Anesthesia, Mayo Clinic, Rochester, Minn.
authors.forename: Martin D
authors.initials: MD
authors.lastname: Abel
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Dearani
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn.
authors.forename: Rick A
authors.initials: RA
authors.lastname: Nishimura
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002312:Cardiomyopathy, Hypertrophic / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery; D005260:Female; D006346:Heart Septum / Q000601:surgery; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery; D008946:Mitral Valve Stenosis / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery; D020127:Recovery of Function; D012307:Risk Factors; D016896:Treatment Outcome; D014463:Ultrasonography; D016277:Ventricular Function, Left; D014694:Ventricular Outflow Obstruction / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery
keywords: hypertrophic cardiomyopathy; mitral stenosis; mitral valve replacement; myectomy