Totally endoscopic septal myectomy combined with mitral valve replacement for suicide left ventricle following transcatheter aortic valve implantation: a case report.

Background: Dynamic left ventricular outflow tract obstruction (LVOTO) causing acute haemodynamic collapse is a rare but life-threatening complication after transcatheter aortic valve implantation (TAVI). Known as suicide left ventricle (SLV), it results from abrupt afterload reduction leading to hypercontractility and dynamic obstruction. Medical therapy is often insufficient, requiring advanced intervention. Case summary: An 88-year-old woman with symptomatic severe aortic stenosis underwent TAVI. Preprocedural echocardiography showed septal hypertrophy without significant LVOTO. Immediately after valve deployment, she developed LVOTO with systolic anterior motion and severe mitral regurgitation, leading to haemodynamic deterioration. Medical management-including volume loading, discontinuation of inotropes, and beta-blocker-was ineffective. Catheter-based therapies were unsuitable because of severe leaflet calcification. Therefore, totally endoscopic transmitral septal myectomy with mitral valve replacement was performed. Postoperative echocardiography confirmed resolution of LVOTO and mitral regurgitation. She gradually recovered and was transferred for rehabilitation on postoperative Day 132. Discussion: TAVI can cause SLV in patients with septal hypertrophy. Although transcatheter therapies are generally preferred in patients at high surgical risk, this case demonstrates that totally endoscopic surgery can be a feasible alternative when catheter-based options are not appropriate. Careful preprocedural risk assessment for SLV and consideration of alternative strategies are essential in patients at increased risk of developing this complication.