Alcohol Septal Ablation for Mitral Annular Calcification–Induced LVOT Obstruction

BACKGROUND: Mitral annular calcification (MAC) can rarely extend into the left ventricular outflow tract (LVOT), causing dynamic obstruction that mimics hypertrophic cardiomyopathy. Management is especially challenging in patients with prior valve surgery. CASE SUMMARY: A 73-year-old woman with prior surgical aortic and mitral valve replacements presented with exertional dyspnea and fatigue. Echocardiography showed dynamic LVOT obstruction. Cardiac computed tomography revealed dense MAC and subvalvular calcification encroaching on the LVOT. Due to high surgical risk, the heart team pursued alcohol septal ablation. The LVOT gradient decreased from 107 to 40 mm Hg on echocardiography and from 42 to 23 mm Hg invasively. Symptoms improved immediately and were sustained at 30-day follow-up. DISCUSSION: This case illustrates a rare mechanism of LVOT obstruction and highlights alcohol septal ablation as a potential solution in anatomically complex, inoperable patients. TAKE-HOME MESSAGES: MAC-related LVOT obstruction is an uncommon but important diagnostic consideration. Alcohol septal ablation may be a viable option for select high-risk surgical patients.