Dynamic left ventricular outflow tract obstruction caused by afterload reduction induced by intra-aortic balloon counterpulsation

Coddens, J.; Alphen, J. Van; Deloof, Thierry; Hendrickx, Jan F. A.

doi:10.1053/jcan.2002.128437

Cited by 12 publications

(9 citation statements)

References 10 publications

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“…Interventions to increase afterload (the Mueller maneuver, phenylephrine infusion), reduce dynamic LVOT obstruction, whereas maneuvers that decrease afterload (vasodilators or intraaortic balloon counterpulsation) result in augmented LVOT obstruction. [4][5][6][7] AVR leads to an immediate reduction in fixed afterload, which contributes to an increased LVOT flow velocity. 8 The resulting convective acceleration of blood in the LVOT may produce a Venturi effect, drawing the mitral valve anteriorly and creating LVOT obstruction.…”

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confidence: 99%

Combined Transcatheter Aortic Valve Replacement and Emergent Alcohol Septal Ablation

et al. 2013

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A 91-year-old woman presented with worsening exertional dyspnea. Her previous medical history included hypertension, percutaneous coronary intervention with drugeluting stent placement to the mid left anterior descending coronary artery, moderate bilateral carotid atherosclerosis, and moderate chronic obstructive pulmonary disease.Transthoracic echocardiography revealed a normal left ventricular ejection fraction with asymmetric upper septal hypertrophy (posterior wall, 1.3 cm; interventricular septum, 2.0 cm; Figure 1A) but without left ventricular outflow tract (LVOT) obstruction ( Figure 1B) at rest or with a Valsalva maneuver. There was severe aortic valve calcification and stenosis ( Figure 1A and 1C).The patient was referred for transcatheter aortic valve replacement (AVR) via the transfemoral approach. Upon crossing the stenotic aortic valve, the peak-to-peak left ventricle-aorta (LVAo) pressure gradient was recorded at 60 mm Hg (Figure 2A). After deployment of a 23-mm Edwards SAPIEN prosthesis, the patient became hypotensive and the peak-to-peak LV-Ao gradient was recorded at 120 mm Hg ( Figure 2B). Transesophageal echocardiography demonstrated a properly functioning aortic prosthesis and revealed a dynamic obstruction in the LVOT attributable to systolic anterior motion of the mitral valve ( Figure 3A), associated with severe mitral regurgitation ( Figure 3B).After review of the preprocedural coronary angiogram ( Figure 4A), the decision was made to proceed emergently to alcohol septal ablation to relieve the dynamic LVOT obstruction. Isopropyl alcohol (1.5 mL) was infused in the septal perforator, and subsequent angiography revealed occlusion of the vessel ( Figure 4B). Transesophageal echocardiography revealed marked reduction in systolic anterior motion and in the degree of LVOT obstruction and mitral regurgitation, as well ( Figure 5). Hemodynamic tracings demonstrated almostcomplete resolution of the LV-Ao gradient ( Figure 6).The patient was successfully extubated at the conclusion of the case and was discharged from the hospital 5 days later. At 1-month follow-up, transthoracic echocardiography revealed continued reduction in the LV-Ao gradient at rest (15 mm Hg) and minimal increase with provocation by a Valsalva maneuver (18 mm Hg). DiscussionIn patients with aortic stenosis, hypertrophy of the left ventricular myocardium often occurs as a result of the increased myocardial load imposed by the valvular obstruction. In most cases, the hypertrophy is concentric, although some patients present with an asymmetric upper septal hypertrophy with or without dynamic LVOT obstruction. 1-3Our patient demonstrated severe asymmetric upper septal hypertrophy, but had no evidence of LVOT obstruction on dynamic preoperative testing. Upon implantation of the transcatheter prosthesis, however, she developed significant LVOT obstruction. This is likely the result of a number of physiological and anatomic changes. The relationship between afterload and LVOT obstruction has been elucidated by numerous investigators...

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confidence: 99%

Combined Transcatheter Aortic Valve Replacement and Emergent Alcohol Septal Ablation

et al. 2013

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“…It improves systemic blood and diastolic coronary flow, and therefore myocardial oxygen delivery, while reducing afterload and myocardial oxygen demand. On the other hand, it has been recognized that IABP has potential to contribute to hemodynamic deterioration by inducing or worsening LVOTO [5,6]. It is notable that discontinuation of IABP as a single intervention led to complete regression of LVOTO, dramatic increase of her CI, and recovery from cardiogenic shock in the present case in spite of minimal reduction of LVOTO by discontinuation of dopamine and dobutamine, which indicated that IABP primarily induced or worsened dynamic LVOTO by reducing afterload.…”

Section: Discussionmentioning

confidence: 55%

Intra-aortic balloon pump induced dynamic left ventricular outflow tract obstruction and cardiogenic shock after very late stent thrombosis in the left anterior descending coronary artery

Takamura

Dohi

Satomi

et al. 2012

Journal of Cardiology Cases

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“…α 1 -Agonists increase the size of the functional out-flow tract and decrease the LVOT pressure gradient by increasing systemic vascular resistance and end-systolic and end-diastolic left ventricular volume. [10] Inotropes (β-agonists/milrinone) or IABP may worsen the condition by decreasing afterload;[11] hence, they were discontinued in our patient once the diagnosis was suspected. When beta-blockers cannot be used due to shock, dual chamber pacing with low heart rate can be used in reducing heart rate and contractility with subsequent reduction in LVOT gradient.…”

Section: Discussionmentioning

confidence: 99%

Dynamic left ventricular outflow tract obstruction complicating aortic valve replacement: A hidden malefactor revisited

et al. 2010

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It is known that a dynamic left ventricular outflow tract (LVOT) obstruction exists in patients, following aortic valve replacement (AVR) and is usually considered to be benign. We present a patient with dynamic LVOT obstruction following AVR, who developed refractory cardiogenic shock and expired inspite of various treatment strategies. This phenomenon must be diagnosed early and should be considered as a serious and potentially fatal complication following AVR. The possible mechanisms and treatment options are reviewed.

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Dynamic left ventricular outflow tract obstruction caused by afterload reduction induced by intra-aortic balloon counterpulsation

Cited by 12 publications

References 10 publications

Combined Transcatheter Aortic Valve Replacement and Emergent Alcohol Septal Ablation

Combined Transcatheter Aortic Valve Replacement and Emergent Alcohol Septal Ablation

Intra-aortic balloon pump induced dynamic left ventricular outflow tract obstruction and cardiogenic shock after very late stent thrombosis in the left anterior descending coronary artery

Dynamic left ventricular outflow tract obstruction complicating aortic valve replacement: A hidden malefactor revisited

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