Rescue percutaneous transluminal septal myocardial ablation for difficult ventilator weaning in drug-resistant hypertrophic obstructive cardiomyopathy: a case report.

Background: Hypertrophic obstructive cardiomyopathy is a genetic cardiac disorder characterized by left ventricular outflow tract (LVOT) obstruction that can lead to haemodynamic instability. Managing preload in mechanically ventilated patients with hypertrophic obstructive cardiomyopathy is challenging because volume depletion exacerbates LVOT obstruction, whereas fluid overload induces pulmonary congestion. Weaning from mechanical ventilation (MV) in such cases requires precise volume management; however, conventional pharmacological therapy may be insufficient. Moreover, the role of percutaneous transluminal septal myocardial ablation (PTSMA) in the acute phase of symptomatic hypertrophic obstructive cardiomyopathy remains unclear.

Case summary: A 51-year-old woman was admitted with cerebral haemorrhage and underwent emergency craniotomy. The patient experienced repeated episodes of acute heart failure, leading to several resuscitation attempts and requiring extended MV. Echocardiography revealed severe LVOT obstruction (peak LVOT pressure gradient, 119.7 mmHg). Attempts at volume optimization and pharmacological therapy failed to wean from MV or achieve haemodynamic stability. Given the patient's critical condition, rescue PTSMA was performed, which significantly reduced the LVOT gradient, thereby allowing aggressive volume reduction with haemodialysis and successful extubation within a week.

Discussion: This case highlights the role of PTSMA as a rescue therapy for patients with hypertrophic obstructive cardiomyopathy experiencing difficulty weaning from MV and haemodynamic instability. Further studies are warranted to evaluate the safety, efficacy, and long-term outcomes of PTSMA as an acute-phase intervention in critically ill patients with hypertrophic obstructive cardiomyopathy.