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

Panduranga, Prashanth; Maddali, Madan Mohan; Mukhaini, Mohammed; Valliattu, John

doi:10.4103/1658-354x.65118

Cited by 6 publications

(5 citation statements)

References 12 publications

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“… 6 Medical approaches include sufficient volume loading, titrated doses of beta-blockers to promote negative chronotropy and inotropy, and the administration of alpha-1 agonists to decrease the LVOT pressure gradient through increasing systemic vascular resistance. 7 Where medical therapy is unable to adequately relieve the LVOT obstruction, procedural management can be undertaken to optimize anatomy. SAM post-SAVR leading to such severe haemodynamic instability remains a rare occurrence, more frequently being described in the post-MVR and TAVR population, and as such there is currently no consensus about definitive management should medical therapy fail.…”

Section: Discussionmentioning

confidence: 99%

Unexpected suicide left ventricle post-surgical aortic valve replacement requiring veno-arterial extracorporeal membrane oxygenation support despite gold-standard therapy: a case report

Lioufas

Kelly

Brooks

et al. 2022

European Heart Journal - Case Reports

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Background Suicide left ventricle is a well-documented phenomenon occurring after valve replacement, however it is most commonly described in the mitral valve replacement (MVR) and trans-catheter aortic valve replacement (TAVR) population. Cases within the surgical aortic valve replacement (SAVR) population usually resolve with optimal medical and interventional therapies. We describe a case of left ventricular suicide following SAVR presenting with persistent haemodynamic instability despite currently accepted medical and surgical therapies. Case Summary A 62-year-old male with severe aortic stenosis presented for surgical aortic valve replacement and a MAZE procedure. There were no significant signs of ventricular hypertrophy on pre-operative trans-thoracic echocardiogram (TTE). Intraoperatively there was mild chordal systolic anterior motion of the mitral valve (SAM) which only occurred when underfilled. During recovery in the ICU the patient’s pulmonary arterial pressures were noted to rise with worsening cardiac output. Subsequent TTE showed severe dynamic left ventricular outflow tract obstruction secondary to SAM. Due to refractory medical management, an alcohol septal ablation was performed. Despite resolution of obstruction, the patient exhibited biochemical signs of systemic hypoperfusion, and thus VA-ECMO support was initiated. Following 72 hours of VA-ECMO support, the patient was weaned with complete resolution of biochemical insults. He was subsequently discharged from the hospital without complication. Discussion Compared to the TAVR population, suicide ventricle post SAVR is comparatively rare. Patients who exhibit persistent impaired cardiac output post-operatively should be investigated rapidly with echocardiography. Furthermore resolution of a LVOTO state from procedural intervention may not immediately follow with improved cardiac output, and may require further supportive management.

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Section: Discussionmentioning

confidence: 99%

Unexpected suicide left ventricle post-surgical aortic valve replacement requiring veno-arterial extracorporeal membrane oxygenation support despite gold-standard therapy: a case report

Lioufas

Kelly

Brooks

et al. 2022

European Heart Journal - Case Reports

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“…[2] The various risk factors contributing to dynamic postoperative LVOTO are enlisted in Table 1. [34]…”

Section: Risk Factorsmentioning

confidence: 99%

“…Various echocardiographic parameters in the preoperative as well as in the immediate postoperative period can predict the subsequent development of LVOTO after AVR. Figure 1[313141516] depicts the various anatomical, physiological, and geometrical echocardiographic findings which present an elevated risk of postoperative LVOTO.…”

Section: Echocardiographic Prediction Of Postoperative Left Ventriculmentioning

confidence: 99%

“…A preoperative documentation of a narrow LVOT is another strong predictor for a postoperative high gradient in the LVOT. [3] The normal LVOT diameter is usually 20 ± 2 mm and can vary in accordance with the body surface area. [17] LVOT diameter should be routinely assessed in the preoperative TEE in the ME aortic valve LAX view by the measurement of the endocardium to endocardium distance of the LVOT within 1 cm of the insertion point of the aortic valve leaflets in midsystole.…”

Section: Echocardiographic Prediction Of Postoperative Left Ventriculmentioning

confidence: 99%

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Left ventricular outflow tract obstruction following aortic valve replacement: A review of risk factors, mechanism, and management

et al. 2019

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The presence of dynamic left ventricular outflow tract obstruction (LVOTO) can complicate the postoperative course of patients undergoing surgical aortic valve replacement (AVR). The phenomenon of LVOTO is a consequence of an interplay of various pathoanatomic mechanisms. The prevailing cardiovascular milieu dictates the hemodynamic significance of the resultant LVOTO in addition to the anatomical risk factors. A thorough understanding of the predisposing factors, mechanism, and hemodynamic sequel of the obstruction is pivotal in managing these cases. A comprehensive echocardiographic examination aids in risk prediction, diagnosis, severity characterization, and follow-up of management efficacy in the setting of postoperative LVOTO. The armamentarium of management modalities includes conservative (medical) and surgical options. A stepwise approach should be formulated based on the physiological and anatomical substrates predisposing to LVOTO. The index phenomenon occurs more frequently than appreciated and should be considered when the post-AVR patients exhibit hemodynamic instability unresponsive to conventional supportive measures. The present article provides an overview of various peculiarities of this under-recognized phenomenon in the context of the perioperative management of patients undergoing AVR.

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“…In the outpatient setting, LVOT obstruction (LVOTO) is typically associated with hypertrophic cardiomyopathy but can occur in structurally normal hearts or in cases of LV hypertrophy in the context of hypovolaemia and inappropriate inotrope use (12) . Its incidence increases post-cardiac surgery and myocardial infarction ( 13 , 14 ). Clinically, LVOTO appears as a low CO state refractory to inotropes.…”

Section: Role Of Echocardiography In Haemodynamic Managementmentioning

confidence: 99%

CRITICAL CARE ECHO ROUNDS: Haemodynamic instability

Roshdy¹,

Francisco²,

Rendon³

et al. 2014

Echo Research and Practice

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The use of echocardiography, whilst well established in cardiology, is a relatively new concept in critical care medicine. However, in recent years echocardiography's potential as both a diagnostic tool and a form of advanced monitoring in the critically ill patient has been increasingly recognised. In this series of Critical Care Echo Rounds, we explore the role of echocardiography in critical illness, beginning here with haemodynamic instability. We discuss the pathophysiology of the shock state, the techniques available to manage haemodynamic compromise, and the unique role which echocardiography plays in this complex process.CaseA 69-year-old female presents to the emergency department with a fever, confusion and pain on urinating. Her blood pressure on arrival was 70/40, with heart rate of 117 bpm Despite 3 l of i.v. fluid she remained hypotensive. A central venous catheter was inserted and noradrenaline infusion commenced, and she was admitted to the intensive care unit for management of her shock state. At 6 h post admission, she was on high dose of noradrenaline (0.7 μg/kg per min) but blood pressure remained problematic. An echocardiogram was requested to better determine her haemodynamic state.

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

Cited by 6 publications

References 12 publications

Unexpected suicide left ventricle post-surgical aortic valve replacement requiring veno-arterial extracorporeal membrane oxygenation support despite gold-standard therapy: a case report

Unexpected suicide left ventricle post-surgical aortic valve replacement requiring veno-arterial extracorporeal membrane oxygenation support despite gold-standard therapy: a case report

Left ventricular outflow tract obstruction following aortic valve replacement: A review of risk factors, mechanism, and management

CRITICAL CARE ECHO ROUNDS: Haemodynamic instability

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