Isolated posterior mitral leaflet elongation as a rare mechanism of systolic anterior motion in hypertrophic cardiomyopathy: a case report of successful treatment with mavacamten.

Background: Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiac disorder. Left ventricular outflow tract (LVOT) obstruction typically results from systolic anterior motion (SAM) of the anterior mitral leaflet. Case summary: We describe a 26-year-old man with HCM in whom SAM was generated by isolated elongation of the posterior mitral leaflet, a rare mechanism with important clinical implications. He was diagnosed during childhood by a paediatric cardiologist and followed until transition to adult care. On presentation, he was in NYHA (New York Heart Association) class II with asymmetric septal hypertrophy (25 mm) and posterior leaflet elongation causing LVOT obstruction. Cardiac magnetic resonance confirmed hypertrophy and late gadolinium enhancement at the site of maximal wall thickness. Genetic testing revealed a pathogenic Discussion: This case illustrates an unusual anatomical substrate for LVOT obstruction in HCM and emphasizes the role of multimodality imaging in diagnosis. It also highlights the therapeutic potential of myosin inhibition with mavacamten in avoiding invasive interventions in complex phenotypes.