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.