{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,13]],"date-time":"2026-08-13T19:35:20Z","timestamp":1786649720714,"version":"build-2736575974"},"reference-count":13,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"3","license":[{"start":{"date-parts":[[2025,7,1]],"date-time":"2025-07-01T00:00:00Z","timestamp":1751328000000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-sa\/4.0"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2025,7]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>The Doppler-derived gradient depends on the magnitude of the flow across a narrowed orifice and the alignment of the Doppler with the flow. Septal myectomy is indicated in symptomatic obstructive hypertrophic cardiomyopathy (HCM) patients with peak instantaneous gradient &gt; 50 mmHg. Chordal rupture has been reported infrequently in obstructive HCM patients, which may hide left ventricular outflow tract (LVOT) gradient because of a decreased forward flow across the LVOT, posterior shift of the coaptation point due to flail posterior mitral leaflet widening the LVOT, or absence of systolic anterior motion (SAM). An increase in the flow across the LVOT will occur after mitral valve repair, which may manifest as an increased LVOT gradient. In a clinical scenario of the simultaneous presence of severe mitral regurgitation, severe septal hypertrophy, and low gradient across the LVOT, the dilemma is whether to perform a septal myectomy in addition to MV repair. An unexpected increase in the LVOT gradient occurred despite septal myectomy in a patient with mitral regurgitation after mitral valve repair. We discuss the necessity of septal myectomy in the presence of a low LVOT gradient, severe mitral regurgitation, and posterior shift of the coaptation point due to posterior leaflet flail and chordal rupture.<\/jats:p>","DOI":"10.4103\/aca.aca_225_24","type":"journal-article","created":{"date-parts":[[2025,7,9]],"date-time":"2025-07-09T12:00:49Z","timestamp":1752062449000},"page":"317-320","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Paradoxical Increase in Left Ventricular Outflow Tract Gradient in a Patient Undergoing Mitral Valve Repair and Septal Myectomy"],"prefix":"10.4103","volume":"28","author":[{"given":"Devika","family":"Poduval","sequence":"first","affiliation":[{"name":"Departments of Cardiac Anaesthesia, Amrita Institute of Medical Sciences, Kochi, Kerala, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thushara","family":"Madathil","sequence":"additional","affiliation":[{"name":"Departments of Cardiac Anaesthesia, Amrita Institute of Medical Sciences, Kochi, Kerala, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"P","family":"Nagarjuna","sequence":"additional","affiliation":[{"name":"Departments of Cardiac Anaesthesia, Amrita Institute of Medical Sciences, Kochi, Kerala, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tony","family":"Joseph","sequence":"additional","affiliation":[{"name":"Departments of Cardiac Anaesthesia, Amrita Institute of Medical Sciences, Kochi, Kerala, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Praveen","family":"Varma","sequence":"additional","affiliation":[{"name":"Cardiac Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"PK","family":"Neema","sequence":"additional","affiliation":[{"name":"Departments of Cardiac Anaesthesia, Amrita Institute of Medical Sciences, Kochi, Kerala, India"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2025,7,8]]},"reference":[{"key":"R1-20250709","doi-asserted-by":"crossref","first-page":"1020054","DOI":"10.3389\/fcvm.2022.1020054","article-title":"Different mechanisms of mitral regurgitation in hypertrophic cardiomyopathy: A clinical case and literature review","volume":"9","author":"Molisana","year":"2022","journal-title":"Front Cardiovasc Med"},{"key":"R2-20250709","first-page":"103","article-title":"Complete resolution of left ventricular outflow tract obstruction after spontaneous mitral valve chordal rupture in a patient with hypertrophic cardiomyopathy","volume":"3","author":"Ieki","year":"2019","journal-title":"CASE (Phila)"},{"key":"R3-20250709","doi-asserted-by":"crossref","first-page":"2219","DOI":"10.1016\/S0735-1097(00)01019-6","article-title":"Mitral regurgitation in hypertrophic obstructive cardiomyopathy: Relationship to obstruction and relief with myectomy","volume":"36","author":"Yu","year":"2000","journal-title":"J Am Coll Cardiol"},{"key":"R4-20250709","doi-asserted-by":"crossref","first-page":"613","DOI":"10.1016\/j.echo.2024.02.010","article-title":"Obstruction in hypertrophic cardiomyopathy: Many faces","volume":"37","author":"Abbasi","year":"2024","journal-title":"J Am Soc Echocardiogr"},{"key":"R5-20250709","doi-asserted-by":"crossref","first-page":"860","DOI":"10.1016\/j.cjca.2023.12.009","article-title":"Mitral valve interventions for hypertrophic obstructive cardiomyopathy","volume":"40","author":"Shuvy","year":"2024","journal-title":"Can J Cardiol"},{"key":"R6-20250709","doi-asserted-by":"crossref","first-page":"1497","DOI":"10.1016\/j.jacc.2016.07.735","article-title":"Mitral regurgitation in patients with hypertrophic obstructive cardiomyopathy: Implications for concomitant valve procedures","volume":"68","author":"Hong","year":"2016","journal-title":"J Am Coll Cardiol"},{"key":"R7-20250709","doi-asserted-by":"crossref","first-page":"242","DOI":"10.1016\/0735-1097(92)90166-K","article-title":"Mitral regurgitation due to ruptured chordae tendineae in patients with hypertrophic obstructive cardiomyopathy","volume":"20","author":"Zhu","year":"1992","journal-title":"J Am Coll Cardiol"},{"key":"R8-20250709","doi-asserted-by":"crossref","first-page":"244","DOI":"10.1016\/j.acvd.2015.01.003","article-title":"Rupture of mitral valve chordae in hypertrophic cardiomyopathy","volume":"108","author":"Boissier","year":"2015","journal-title":"Arch Cardiovasc Dis"},{"key":"R9-20250709","first-page":"153","article-title":"Acute mitral regurgitation due to ruptured chordae tendineae in a patient with hypertrophic obstructive cardiomyopathy: A case report","volume":"47","author":"Koshino","year":"2006","journal-title":"J Cardiol"},{"key":"R10-20250709","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1056\/NEJM199707033370107","article-title":"Valvular heart disease","volume":"337","author":"Carabello","year":"1997","journal-title":"New Engl J Med"},{"key":"R11-20250709","doi-asserted-by":"crossref","first-page":"1382","DOI":"10.1016\/S0140-6736(09)60692-9","article-title":"Mitral regurgitation","volume":"373","author":"Enriquez-Sarano","year":"2009","journal-title":"Lancet"},{"key":"R12-20250709","doi-asserted-by":"crossref","first-page":"390","DOI":"10.1016\/j.jacc.2021.11.021","article-title":"Management of hypertrophic cardiomyopathy: JACC state-of-the-art review","volume":"79","author":"Maron","year":"2022","journal-title":"J Am Coll Cardiol"},{"key":"R13-20250709","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1016\/j.jtcvs.2015.09.068","article-title":"Septal myectomy for patients with hypertrophic cardiomyopathy: A new paradigm","volume":"151","author":"Nishimura","year":"2016","journal-title":"J Thorac Cardiovasc Surg"}],"container-title":["Annals of Cardiac Anaesthesia"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.4103\/aca.aca_225_24","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,13]],"date-time":"2026-08-13T18:57:37Z","timestamp":1786647457000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.4103\/aca.aca_225_24"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7]]},"references-count":13,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2025]]}},"URL":"https:\/\/doi.org\/10.4103\/aca.aca_225_24","relation":{},"ISSN":["0971-9784","0974-5181"],"issn-type":[{"value":"0971-9784","type":"print"},{"value":"0974-5181","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,7]]},"assertion":[{"value":"2024-11-03","name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-02-15","name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}