Transcatheter aortic valve replacement for aortic regurgitation after septal myectomy in patients with obstructive hypertrophic cardiomyopathy

Transaortic septal myectomy is currently considered to be the most appropriate surgical treatment for patients with obstructive hypertrophic cardiomyopathy (HCM) and heart failure symptoms unresponsive to medical therapy (1). However, a well-described late complication of this approach is the development of a substantial aortic regurgitation (AR), frequently requiring surgical aortic valve replacement (SAVR) (2). Post-myectomy AR may be secondary to the leaflet trauma at the time of surgery since septal myectomy is performed through the aortic valve after aortotomy; secondly, it may be related to the turbulent blood flow in the left ventricle outflow tract after surgery that in turn may cause recurrent trauma to the valve in systole; lastly, septal myectomy involves a piece of myocardium below the right coronary cusp and over time the derangement of septal structure may alter the support of the aortic valve causing gradual distortion of the aortic annulus. A redo SAVR is usually associated with an increased risk profile due to the presence of adherences and comorbidities. Although some studies reported encouraging results (3), TAVR is still an off-label indication for AR.