Search Results (70)

Background: Some dogs with severe mitral valve regurgitation can have chronic cough, but its cause is unclear. Many of these dogs exhibit left principal (synonym mainstem) bronchial collapse or compression. Some clinicians believe that an enlarged heart, particularly the dilated left atrium, compresses the left principal bronchus, while others argue that a healthy bronchus cannot be compressed and that the cough is due to concurrent airway disease, such as bronchomalacia. In this study, we aimed to investigate the correlation between chronic cough and radiographic signs of bronchial narrowing in dogs with cardiomegaly secondary to primary mitral valve regurgitation. Methods: Four radiologists independently evaluated 51 sets of thoracic radiographs from client-owned dogs with cardiomegaly due to severe mitral valve regurgitation, including 26 sets of radiographs belonging to dogs with chronic (>8 weeks) cough and 25 without cough. The presence or absence of bronchial narrowing was assessed while the radiologists were blinded to patient characteristics and each other’s findings. Results: Interobserver variability was high, and the radiologists could not reliably predict which dogs had a chronic cough. Dogs with left atrial enlargement and airway narrowing sometimes coughed and sometimes did not. Likewise, some dogs with left atrial enlargement but no signs of airway compression or collapse coughed, and some did not. It was impossible to distinguish the groups based on these features. Conclusion: Bronchial compression by an enlarged heart and left atrium is an unlikely cause of chronic cough in dogs with severe primary mitral valve regurgitation. Full article

Background: Anemia is a common comorbidity in heart failure (HF) and has been associated with adverse clinical consequences. This retrospective, descriptive cohort study examined phenotype-specific differences in anemia severity, clinical presentation, comorbid burden, and in-hospital management across HF subtypes classified by left ventricular ejection fraction (LVEF). Methods: We retrospectively analyzed 443 adult patients hospitalized with concurrent HF and anemia from January 2022 to December 2024. Patients were stratified by LVEF into HFrEF (<40%), HFmrEF (40–49%), and HFpEF (≥50%). All patients included met WHO criteria for anemia. Demographic, clinical, paraclinical, and therapeutic data were extracted, and descriptive statistical methods were used to evaluate intergroup differences. No formal time-to-event analyses (e.g., Kaplan–Meier curves) were performed; instead, exploratory cumulative readmission analyses using fixed follow-up windows were conducted. In-hospital mortality was recorded and stratified by HF phenotype. Results: The cohort comprised 213 (48.0%) HFrEF, 118 (26.6%) HFmrEF, and 112 (25.3%) HFpEF patients. The distribution of anemia severity, management strategies, and comorbidity profiles varied significantly across phenotypes. Severe anemia predominated in the HFmrEF cohort (54.2%), whereas mild anemia was most common in HFpEF (52.1%) and HFrEF (52.1%). Mean hemoglobin concentrations were 8.39 ± 1.79 g/dL (HFmrEF), 9.07 ± 2.47 g/dL (HFpEF), and 8.62 ± 1.94 g/dL (HFrEF). Rates of atrial fibrillation (48.2% in HFpEF), hypertensive ECG changes (63.4% in HFpEF), and ischemic-lesion patterns (>50% in HFrEF) differed by cohort. Echocardiographically, grade III mitral regurgitation and severe pulmonary hypertension each affected 25.4% of HFmrEF patients, whereas HFpEF patients most often exhibited grade II mitral regurgitation (42.9%) and moderate pulmonary hypertension (42.9%). HFrEF patients had severe pulmonary hypertension. Intravenous (IV) iron was the primary treatment modality, with highest utilization in HFmrEF. IV iron use ranged from 69.9% (HFrEF) to 84.8% (HFmrEF), with transfusion rates of 5.6% (HFrEF)–16.1% (HFpEF). Comorbid burdens differed by phenotype: HFrEF was associated with structural heart disease, HFmrEF with vascular and hepatic pathology, and HFpEF with metabolic and degenerative comorbidities. Discharge pharmacotherapy reflected phenotype-specific treatment patterns. Conclusions: This real-world descriptive analysis highlights substantial variation in anemia burden and management across the HF spectrum. While limited to descriptive findings, our analysis highlights the heterogeneity of anemia in HF and describes observed associations across phenotypes, without implying causality. These findings should be interpreted as hypothesis-generating. These findings are observational, exploratory, and cannot establish a causal relationship between intravenous iron use and survival. Full article

Background: Several treatment strategies are available for patients with mitral valve regurgitation (MR). However, evidence regarding their comparative effectiveness remains limited. We sought to compare the performance of different treatment strategies for personalized treatment of patients with MR. Methods: We performed a pairwise and network meta-analyses of randomized trials comparing treatment strategies for patients with MR. Patients were divided in two groups: transcatheter mitral valve repair (TMVR, including edge-to-edge repair and indirect percutaneous annuloplasty) and control (surgery or optimal medical therapy). The primary outcome of this analysis was all-cause death. Main secondary outcomes were re-hospitalization for heart failure and re-intervention. Results: A total of seven trials with 2324 participants, with mainly functional MR (TMVR, n = 1373-control, n = 951) were available for the quantitative synthesis. The median follow-up duration was 14 months. Compared to control therapy, TMVR significantly reduced all-cause death (RR 0.77, 95% CI 0.65–0.91, p = 0.002) and re-hospitalization for heart failure (RR 0.67, 95% CI 0.49–0.91, p = 0.01). Among TMVR strategies, the edge-to-edge repair with MitraClip ranked as possibly the best option to reduce all-cause death. Conclusions: In symptomatic patients with significant MR, TMVR is associated with a significant reduction of all-cause death, and re-hospitalization for heart failure, mainly in patients with functional MR. Additional comparative studies are needed to investigate the best TMVR treatment option, for patients with degenerative MR. Full article

Background: The transapical off-pump NeoChord procedure is a recognized minimally invasive surgical approach for the treatment of severe degenerative mitral regurgitation. This study aims to report the initial Greek experience with the NeoChord procedure, presenting mid-term clinical and echocardiographic outcomes from a single cardiothoracic surgical center, with a median follow-up duration of 20 months. Methods: In this study, 42 symptomatic patients with moderate to severe and severe primary mitral regurgitation underwent mitral valve repair with the Neochord procedure between March 2018 and December 2024. All patients were evaluated clinically and echocardiographically by the Heart team preoperatively, after 1 month, and at the last follow-up (end of 2024). The primary endpoint was established as the presence of a major clinical event (all-cause mortality, reintervention due to deterioration of MR, and cardiac-related rehospitalization). Results: The median age of patients was 69 [61.75–79.25] years, and 69% of patients were men. The median EuroScore II was 1.79 [1.32–2.48], and the STS-PROM MV repair score was 3.18 [2.28–4.66]. Regarding the preprocedural mitral valve anatomical evaluation, 35 patients had type A (83.3%),4 had type B(9.5%), whereas only two patients had type C and 1 with type D anatomy. The median of LAI was 1.2 [1.15–1.25], whereas the CI was 4 [2.15–5]. More than two neochordae were implanted in 34 patients (81%). MR severity improved at 1-month (<moderate:92.85%) and at the last follow-up (<moderate:92.1%). NYHA class decreased within 1 month (I + II: 95.23%) after the procedure and was maintained at the last follow-up (I + II: 94.73%). The median left ventricular ejection fraction (LVEF) before the procedure was 63 [58–67]%, which significantly decreased to 57 [53–61]% at the 1-month follow-up (2-sided p < 0.001). At the final follow-up, LVEF increased to 65 [60–68]%, however, this change was not statistically significant compared to the preprocedural value. During the follow-up period, four deaths were documented—three due to non-cardiac and one attributable to a cardiac cause. Two cases proceeded to reoperation for surgical valve implantation due to recurrent mitral valve regurgitation 6 months and 8 months after the NeoChord procedure. Conclusions: Transapical off-pump NeoChord implantation offers a minimally invasive alternative to conventional surgery for symptomatic patients with moderate-to-severe or severe primary mitral regurgitation. Among patients with suitable mitral valve anatomy, the procedure has demonstrated a favorable safety profile and promising mid-term outcomes, in terms of cardiac mortality, as well as freedom from reoperation and rehospitalization. Full article

Mitral regurgitation (MR) is a common valvular heart disease associated with significant morbidity and mortality. For patients at high or prohibitive surgical risk, mitral transcatheter edge-to-edge repair (M-TEER) offers a less invasive alternative to surgery. This review outlines key aspects of patient selection and procedural planning for M-TEER, with a focus on clinical and echocardiographic criteria essential for success. Comprehensive imaging—especially 2D and 3D transesophageal echocardiography—is critical to assess leaflet anatomy, coaptation geometry, and mitral valve area. Selection criteria differ between primary and secondary MR and are guided by trials such as COAPT and MITRA-FR. Optimal outcomes rely on careful screening, anatomical suitability, and multidisciplinary evaluation. With growing experience and advancing technology, M-TEER has become a transformative option for treating severe MR in non-surgical candidates. Full article

Background: Chronic mitral regurgitation (MR) is categorized into primary and secondary MR (SMR). While primary MR arises from structural abnormalities of the mitral valve apparatus, SMR is a consequence of cardiac remodeling, typically due to heart failure or atrial fibrillation. Management strategies differ significantly, with primary MR requiring direct valvular intervention and SMR necessitating a comprehensive approach incorporating guideline-directed medical therapy (GDMT), revascularization, and resynchronization strategies. The MitraClip, a transcatheter edge-to-edge repair (TEER) device, has emerged as a recommended intervention for symptomatic severe SMR despite optimal GDMT. Objectives: This study aims to evaluate national trends in MitraClip placements in the U.S. from 2016 to 2021 and to assess 90-day readmission events following the procedure. Additionally, we analyze patient and socioeconomic factors associated with heart failure readmissions post-MitraClip placement to optimize patient selection criteria. Methods: The study utilized data from the National Inpatient Sample (NIS) for the years 2016–2021 and the National Readmissions Database (NRD) for 2021. Patients who underwent MitraClip placement were identified using ICD-10 code 02UG3JZ. We stratified the population based on demographics, hospital resource utilization, and comorbidities. Index admissions were classified based on the presence or absence of heart failure remissions within 90 days post-procedure. Statistical analyses, including ANOVA and logistic regression, were conducted to identify factors associated with readmissions. Results: MitraClip utilization demonstrated a rising trend from 2016 to 2021, with total annual procedures increasing from 869 to 2488. Mean patient age remained stable at 76–79 years, with a nearly equal sex distribution. In-hospital mortality remained low (1–3%) throughout the study period. A steady increase in hospital charges was observed, alongside a decline in the mean length of stay. Analysis of 4918 index admissions for MitraClip placement in 2021 identified 780 total readmissions within 90 days, with 206 (26.4%) attributed to heart failure. Factors significantly associated with increased risk of heart failure readmissions included atrial fibrillation (OR 3.77, CI 1.82–4.23), pulmonary hypertension (OR 3.96, CI 1.49–5.55), and chronic lung disease (OR 1.91, CI 1.32–2.77). Conclusions: The increasing adoption of MitraClip underscores its growing role in managing SMR. However, heart failure readmissions remain a significant concern. Identifying high-risk patient profiles can refine selection criteria and enhance post-procedural management strategies to improve clinical outcomes. Further research is needed to optimize patient selection and refine risk stratification for MitraClip interventions. Full article

Background and Objectives: MitraClip^® (MC) placement has been extensively used as an intervention for mitral transcatheter edge-to-edge repair (mTEER) for functional mitral regurgitation (FMR). The aim of our study is to analyze the association between the pre-procedural echocardiographic parameters of diastolic function (DF) and one-year outcomes after MC placement. Materials and Methods: The study was designed in a retrospective longitudinal cross-sectional format. In total, 224 patients who underwent MC placement between January of 2021 and March of 2024 were included in the study. The Primary Efficacy Endpoint (PEE) was determined by an absence of heart failure hospitalizations requiring Intravenous Diuretics or cardiac-related death in the one-year follow-up period. Multivariate regression analysis was carried out to identify the pre-procedural echocardiographic parameters of DF that had a significant association with a failure to reach the PEE. A two-tailed p-value < 0.05 was used to determine statistical significance. Results: Of the 224 patients included in the study, 85 patients (37.94%) failed to reach the PEE or had worsening symptoms. The mean mitral valve (MV) deceleration time was 176.88 ms (164.14–189.62) in the symptom-worsening group compared to 201.53 ms (186.01–217.07) in the symptom-improvement group. The mean of the E/A ratio (MV peak E velocity/A velocity) was noted to be 2.35 (1.97–2.74) in the symptom-worsening group compared to 1.90 (1.68–2.13) in the symptom-improvement group. After multivariate regression analysis, the E/A ratio was found to have a significant association with a failure to reach PEE: Odds Ratio (OR): 1.61 (1.13–2.29), p-value: 0.008. The area under the curve (AUC) analysis for the E/A ratio was calculated at 0.603 (0.50–0.69) for the symptom-worsening group. Conclusions: Patients that failed to reach the PEE had a lower pre-procedural MV deceleration time of 176.88 ms (164.14–189.62); however, no association was observed between MV deceleration time and a failure to reach the PEE in the multivariate regression analysis. The pre-procedural E/A ratio had a significant association with symptom worsening after multivariate regression analysis: OR: 1.61 (1.13–2.29). The AUC for the E/A ratio in the symptom-worsening group was 0.603, making it a more moderate predictor than random guessing for the failure to reach the PEE. Full article

Introduction: Assessment of left ventricular (LV) systolic function is important in valvular heart disease. The global LV contractility index, dσ*/dt_max, is load-independent and has been reported to be associated with clinical outcomes in heart failure and aortic stenosis. We aim to assess if dσ*/dt_max could predict adverse outcomes in patients with severe mitral regurgitation (MR). Methodology: We studied dσ*/dt_max in a cohort of 127 patients with isolated severe primary MR and preserved LVEF ≥ 60%. Patients with prior valvular intervention or concurrent valvular disease were excluded. We tested dσ*/dt_max against a composite of adverse outcomes including all-cause mortality, heart failure hospitalization, and mitral valve intervention. Results: The cohort had a mean age of 58 years old and was predominantly male. Of the 127 patients, eight (6.3%) needed subsequent hospitalization for heart failure, while 30 (23.6%) and 11 (8.7%) patients underwent mitral valve repair and replacement, respectively, And 14 (11.0%) passed away. Of the patients (n = 54 (42.5%)) who had an adverse outcome during follow-up, dσ*/dt_max demonstrated an independent association with composite adverse outcome, including its individual components. On ROC analysis, a cut-off of 2.15 s⁻¹ was identified. Based on this cut-off, dσ*/dt_max retained an independent association with composite adverse outcome after adjusting for covariates including age, sex, ischemic heart disease, pulmonary artery systolic pressure, and left ventricular end systolic diameter. Conclusions: In patients with severe primary MR and preserved LVEF, reduced dσ*/dt_max was an independent predictor of adverse outcomes. It can be a useful addition to the armamentarium for assessing patients with severe MR. Full article

Background: Posterior mitral leaflet hypoplasia is a rare condition, generally diagnosed in children. This paper presents three adult cases of posterior leaflet hypoplasia and comprehensively reviews the existing literature. Methods and Results: All patients presented with severe mitral regurgitation necessitating hospitalization. Transthoracic and transesophageal echocardiography were performed to determine the underlying etiology, revealing pronounced posterior mitral leaflet hypoplasia. Each case was evaluated by a multidisciplinary heart team. Surgical mitral valve intervention was feasible in two patients. In one high-risk patient, percutaneous treatment options for MR were explored but ultimately deemed unsuitable due to the anatomical characteristics of the valve. The patient was consequently managed conservatively with medical therapy. Conclusions: These cases demonstrate that posterior mitral leaflet hypoplasia may constitute an underrecognized cause of severe primary mitral regurgitation in adults. The management of such cases can be particularly challenging due to the atypical valvular morphology. Full article

Background/Objectives: Mitral regurgitation (MR) is the most common left heart valve disease, but its exact prevalence remains uncertain. To estimate the prevalence of MR we conducted a systematic review and meta-analysis of population-based studies. Methods: We searched the Medline/PubMed, Embase, and Scopus databases, in January 2023, for studies reporting or allowing for the calculation of the prevalence of moderate-to-severe MR in the general population. Eligible studies included those using echocardiography or primary care databases from countries with universal healthcare. Studies where echocardiography was performed for medical indications were excluded. Random-effects meta-analysis was used to calculate the pooled estimates. Subgroup and meta-regression analyses were employed to investigate the reasons for heterogeneity. Mixed-model multivariable meta-regression was used to estimate age- and sex-specific prevalence. Results: After screening 13,847 records, we identified 20 eligible studies (22 study populations) including 6,036,691 individuals. The global prevalence of moderate-to-severe MR was 0.67% (95% CI, 0.33−1.11). Prevalence increased greatly with age, and it was estimated to be approximately 0.63% (0.25–1.16) at age 50, 2.85% (1.96–3.90) at 70, and 6.45% (4.17–9.16) by 90 years. North America showed the largest crude prevalence (1.11%; 0.52−1.88), followed by Europe (0.60%; 0.34−0.92), Asia (0.24%; 0.00−0.92), and Africa (0.16%; 0.03−0.37). Differences in prevalence by geographic region and ethnic group were primarily attributable to population age. Prevalence did not differ by sex, study year, or diagnostic criteria. Conclusions: Moderate-to-severe MR is a prevalent condition, particularly among elderly people. With rising life expectancy worldwide, ensuring universal access to interventions will be vital to reduce morbidity and mortality. Full article

Background: In patients with significant mitral regurgitation (MR) undergoing transcatheter edge-to-edge repair (M-TEER), assessment of mitral valve (MV) anatomy is essential. While transthoracic echocardiography (TTE) is the initial diagnostic tool, transesophageal echocardiography (TOE) provides better anatomical details. The study aims to assess whether TTE is as effective as TOE in selecting patients with severe MR who are eligible for M-TEER. Methods: From January to December 2024, patients with severe MR eligible for TEER were enrolled at the Fondazione Monasterio Heart Hospital, Italy. They underwent a comprehensive TTE and TOE examination. Cardiologists assessed the severity of MR and valve anatomy using specific protocols. Measurements included MV area, MV gradient, posterior leaflet length, fossa ovalis high, presence of fails, clefts, and calcifications. Three levels of anatomic complexity were defined to determine eligibility for TEER. Results: The study includes 40 patients with severe MR. The correlation between TTE and TOE for key parameters was strong, with coefficients ranging from 0.734 to 0.901, indicating high agreement between the two methods. The comparison of categorical features showed high agreement between TTE and TOE in detecting critical MV conditions, with kappa values ranging from 0.717 to 0.930. The agreement for classifying patients as suitable for M-TEER was 87.5%, indicating moderate consistency between the two methods. Conclusions: TTE may be a viable alternative to TOE for assessing MV anatomy and function before M-TEER in MR patients, especially in high-volume centers. While TTE strongly correlated with TOE for most parameters, TOE was superior for some features. Further research is needed to refine the clinical application of TTE and to define patient selection criteria for its use as the primary imaging modality for pre-procedural M-TEER screening. Full article

Background and Objectives: Associated mitral regurgitation (MR) is frequently observed during transcatheter aortic valve implantation (TAVI). The progression of moderate MR remains undetermined, given uncertain clinical significance and natural history. This study aims to assess the evolution of moderate MR following TAVI. Materials and Methods: Between 2018 and 2023, 1476 patients underwent TAVI. We excluded those with previous aortic or mitral valve interventions, endocarditis, concomitant percutaneous coronary intervention, or emergent procedures. Patients with severe aortic or tricuspid regurgitation or significant mitral stenosis were excluded. Ultimately, only patients with moderate MR were included, resulting in a final population of 154 patients. Results: Mean age was 81.4 ± 7.8 years, 48.1% (74/154) were female, and 48.1% (74/154) were functional MR. There was one surgical conversion due to annular rupture. Thirty-day mortality was 1.9% (3/154). Postoperative echocardiography showed 38 (24.7%) patients with none/trace MR, 91 (59.1%) with mild MR, 22 (14.3%) with moderate MR, and 3 (1.9%) with severe MR. Finally, according to the echocardiographic follow-up [median follow-up 1.0 (IQR: 0.1–1.2) years], 20.1% (31/154) had no/trace MR, 39.6% (61/154) had mild MR, 35.7% (55/154) had moderate MR, and 4.5% (7/154) had severe MR. Overall, 67 (43.5%) patients had any MR grade progression, 62 (40.3%) had stable disease, and 25 (16.2%) had any MR grade reduction at the last follow-up from the operation. No difference in MR evolution was seen between functional and primary MR. Conclusions: Concomitant moderate MR during TAVI has a variable evolution over time. A more detailed characterization of patients with preoperative moderate MR undergoing TAVI is necessary to identify those with a disease progression risk. Full article

Background/Objectives: Over the past two decades, MitraClip™ therapy has proven to be an effective and safe treatment for severe mitral regurgitation (MR), with more than 200,000 patients treated globally through continuous advancements in device design and implantation techniques. This retrospective, observational, single-center study aimed to assess the safety and efficacy of the latest generation of MitraClip compared to earlier models in the Real-World MitraClip Florence Registry. The primary efficacy endpoint was a comparison in terms of the rate of successful procedures, the time to device deployment and the duration of the hospital stay. The secondary safety endpoint regarded long-term all-cause mortality and hospitalization for heart failure. Methods: Patients treated at our center from January 2016 to June 2022 were included. They were divided into two groups: those receiving early-generation devices (G1–G3) and those treated with the last-generation device (G4). All patients underwent a comprehensive preoperative echocardiographic assessment, with a re-evaluation before hospital discharge and after 12 months. A long-term follow-up focusing on all-cause mortality and hospitalization for heart failure was conducted. Results: Of 131 patients, 81 received the last-generation device. The mean age was 79.4 years. Both groups exhibited a high burden of comorbidities (overall mean n = 2.85). Procedural success was high (97%) across groups, with a significantly better MR reduction (Grade ≤ 1) in the G4 group (47% vs. 70%, p = 0.009). The time to device deployment was significantly shorter with the G4 system (72 vs. 135 min, p < 0.001), and there was a trend towards shorter hospital stays (6.1 vs. 7.9 days, p = 0.08). Kaplan–Meier analysis demonstrated better 5-year survival rates for the last-generation device group (p = 0.019), with no significant difference in rehospitalization rates (p = 0.186). Conclusions: The MitraClip G4 system in the real world for the treatment of severe MR is safe and effective, achieving immediate and durable procedural success, accompanied by an improved NYHA functional class. Moreover, a better long-term survival rate was observed, along with a comparable high rate of recurrent HF hospitalization, reflecting a high comorbidity burden in this frail population. Full article

Background: Secondary mitral regurgitation (SMR) is characterized by a pathological process impacting the left ventricle (LV) as opposed to the mitral valve (MV). In the absence of structural alterations to the MV, the expansion of the LV or impairment of the papillary muscles (PMs) may ensue. A number of technical procedures are accessible for the purpose of determining the optimal resolution for MR. Nevertheless, there is a dearth of rigorous data to facilitate a comparative analysis of MV replacement, MV repair (including subvalvular repair), and transcatheter mitral valve interventions (TMV-Is). The objective of this investigation is to evaluate and compare the efficacy and clinical outcomes of transcatheter mitral valve repair (TMV-r) utilizing the edge-to-edge mitral valve repair (TEER) procedure in comparison to conventional surgical mitral valve interventions (S-SMVis) in patients with secondary mitral regurgitation. Methods and analysis: A consortium of five cardiac surgery institutions from four European states and Japan have joined forces to establish a multicenter observational registry, designated TEERMISO. Patients who underwent technical procedures for SMR between January 2007 and December 2023 will be enrolled consecutively into the TEERMISO registry. The investigation team evaluated the comparative efficacy of replacement and repair techniques, utilizing both the standard surgical methodology and the transcatheter intervention. The primary clinical outcome will be the degree of left ventricular remodeling, as assessed by the left ventricular end-diastolic volume index, at 10 years. The forthcoming research will assess a variety of secondary endpoints, among which all-cause mortality will be the primary endpoint. Subsequent assessments will be made in the following order: functional status, hospitalization, neurocognition, physiological measures (echocardiographic assessment), occurrence of adverse clinical incidents, and reoperation. Ethics and dissemination: The multicenter design of the database is anticipated to reduce the potential for bias associated with institutional caseload and surgical experience. All participating centers possess an established mitral valve protocol that facilitates comprehensive follow-up and management of any delayed mitral complications following replacement surgery or surgical repair of the secondary mitral regurgitation. The data collected will provide insights into the impact of diverse surgical approaches on standard mitral valve surgery and TEER. This will facilitate the evaluation of LV remodeling over the course of long-term post-procedural follow-up. Trial Registration: ClinicalTrials.gov ID: NCT05090540; IRB ID: 202201143 Full article

The combination of hypertrophic cardiomyopathy with outflow tract obstruction, severe pre-capillary and post-capillary pulmonary hypertension, and severe primary mitral regurgitation is rare and presents distinct management challenges. Background and Clinical Significance: Pulmonary hypertension is an independent predictor of all-cause mortality in patients with hypertrophic cardiomyopathy managed medically and often precludes patients from undergoing cardiopulmonary bypass due to increased surgical morbidity and mortality. In studies specifically evaluating surgical myectomy, however, survival is favorable in patients with moderate-to-severe pulmonary hypertension. Case Presentation: We present a case of a 74-year-old male with six months of dyspnea with minimal exertion. A diagnostic work-up with transthoracic echocardiogram showed asymmetric left ventricular hypertrophy, left ventricular outflow tract obstruction with a peak gradient of 200 mmHg, right ventricular systolic pressure of 99 mmHg, systolic anterior motion of the mitral valve and flail anterior mitral leaflet. The patient was evaluated by a multi-disciplinary team and underwent extended septal myectomy and mitral valve repair with significant improvement in functional capacity post-operatively. Conclusions: While pulmonary hypertension increases the risk of morbidity and mortality during cardiopulmonary bypass, moderate-to-severe pulmonary hypertension in hypertrophic cardiomyopathy with outflow tract obstruction is a unique indication for septal reduction therapy that may not be associated with higher surgical mortality. Full article