Images in Cardiovascular Medicine Myectomy Plus Alfieri Technique for Outflow Tract Obstruction in Hypertrophic Cardiomyopathy

56-year-old man presented with breathlessness andchest pain. Echocardiography revealed 14-mm septalhypertrophy, complete systolic anterior motion of the anteriormitral valve leaflet, severe central mitral regurgitation, and aleft ventricular outflow tract gradient of 40 mm Hg increasingto 56 mm Hg on Valsalva. A diagnosis of hypertrophiccardiomyopathy was made.Despite medical therapy, the patient’s symptoms wors-ened. Transesophageal echocardiography and cardiovascularmagnetic resonance imaging (the Figure, top) revealed elon-gation of the anterior mitral valve leaflet but no significantintrinsic disease of the valve. The mitral regurgitation wasthought to be central rather than posterior (as would beexpected to occur as a result of the complete systolic anteriormotion) because of the elongated leaflet.The patient was referred for gradient and mitral regurgita-tion reduction surgery with septal myectomy and mitral valverepair. This was performed under transesophageal guidance.The myectomy was limited by the mild hypertrophy of theseptal wall and by the concern of causing a ventricular septaldefect if too much myocardium was excised. Because of thecomplex nature of the mitral valve anatomy, it was treatedwith the “edge-to-edge” or “Alfieri” technique, in which theA2 scallop is directly sutured to P2.