Unexplained hypotension: The spectrum of dynamic left ventricular outflow tract obstruction in critical care settings*

Chockalingam, Anand; Dorairajan, Smrita; Bhalla, Meenakshi; Dellsperger, Kevin C.

doi:10.1097/ccm.0b013e3181958710

Cited by 48 publications

(53 citation statements)

References 13 publications

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“…However, administration of β-blockers would be reasonable when coro- reasonable because they suppress the basal hypercontractility and increase cardiac filling, thereby reducing the obstruction. 34 Verapamil or diltiazem may provide hemodynamically favorable effects similar to β-blockers. When coronary spasm is suspected, calcium-channel blockers would be more appropriate than β-blockers.…”

Section: Beta-blockersmentioning

confidence: 99%

Clinical Management of Takotsubo Cardiomyopathy

Kurisu

Kihara

2014

Circ J

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Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp stress such as asthma attack or non-cardiac surgery have been identified in previous cases. 3 These stressors are common events that anyone may experience. Men account for a minority of cases; reports range from 4% to 13%. 6-8 In men, physical stress rather than emotional stress is much more associated with the occurrence. 7,8 ElectrocardiographyCommon abnormalities on the initial ECG are ST-segment elevation, negative T wave and subsequent QT interval prolongation (Figure 2). 3-5,9-11 There is a significant variability in frequency because these ECG changes are time-dependent. 12, 13 The typical time course of the ECG is as follows. 12 ST-segment elevation usually occurs shortly after onset. Negative T wave deepens progressively to its first negative peak, which occurs at approximately 3 days. The negative T wave becomes shallow for several days and then deepens, the second negative peak occurring at approximately 2 weeks. QT interval becomes prolonged progressively as the negative T wave deepens. These ECG changes are found in takotsubo cardiomyopathy as well as AMI, and the differential diagnosis is clinically important for appropriate management. Ogura et al reported that the absence of reciprocal changes, the absence of abnormal Q wave and the sum of ST-segment elevation in leads V4-6 more than the sum of ST-segment elevation in leads V1-3 identified takotsubo cardiomyopathy with a high sensitivity and specificity. 14 Kosuge et al recently reported that the combination of ST-segment depression in lead aVR and no STsegment elevation in lead V1, or the combination of positive T wave in lead aVR and no negative T wave in lead aVR, was more useful in identifying takotsubo cardiomyopathy. 15,16 EchocardiographyEchocardiography plays a central role in the diagnosis of takotsubo cardiomyopathy. Typically, RWMA is found in the apical to mid segments of the left ventricle, extending beyond a single coronary territory. Relative compensatory hypercontractility is often found in the basal segment. Other patterns akotsubo cardiomyopathy is an acute cardiac syndrome mimicking acute myocardial infarction (AMI), and is characterized by chest symptoms, electrocardiographic (ECG) changes and reversible regional wall motion abnormality (RWMA) in the apical to mid segments of the left ventricle. 1-5 In contrast to AMI, takotsubo cardiomyopathy exhibits RWMA independent of acute plaque rupture or myocardial ischemia with coronary atherosclerosis during the early stage. RWMA occurs in the apical to mid segments of the left ventricle, extending beyond a single coronary territory (Figure 1), and it usually resolves spontaneously within a matter of days to a few weeks.Takotsubo cardiomyopathy was first reported by Sato et al at Hiroshima City Hospital in 1990, 1-3 since when it has become increasingly recognized worldwide. Several mechanisms, including multivessel coronary artery spasm, coronary microvascular dysfunction or catecholami...

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Section: Beta-blockersmentioning

confidence: 99%

Clinical Management of Takotsubo Cardiomyopathy

Kurisu

Kihara

2014

Circ J

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“…In our experience, LVOTO is a highly variable finding that is dependent on loading conditions, medications, heart rate and circulating catecholamine levels [7,14]. Anterior mitral leaflet (AML) systolic anterior motion (SAM) is classically demonstrated in 70% of hypertrophic cardiomyopathy (HCM) patients at rest or with exercise [15].…”

Section: Prevalence Of Acute Lvot Obstructionmentioning

confidence: 98%

“…Another well recognized setting for transient LVOTO is in about 10% of patients undergoing dobutamine stress echocardiography [16]. Similarly, use of inotropes in critical care settings also predisposes to LVOTO [14]. About 25% of SC subjects likely manifest LVOTO [6].…”

Section: Prevalence Of Acute Lvot Obstructionmentioning

confidence: 98%

“…2D imaging in the parasternal long and apical 5 chamber views are best suited to study the severity and duration of SAM [7]. Mitral valve level M-mode from the parasternal long axis view, when obtainable, may provide adequate temporal resolution to study the severity and duration of AML-septal proximity [14]. Color Doppler guided pulse interrogation in apical long axis and 5 chamber views can help localize the level of obstruction.…”

Section: Prevalence Of Acute Lvot Obstructionmentioning

confidence: 99%

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Echocardiography in stress cardiomyopathy and acute LVOT obstruction

Chockalingam

Xie

Dellsperger

2010

Int J Cardiovasc Imaging

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Widespread use of echocardiography has contributed to more frequent recognition of takotsubo stress cardiomyopathy. Initial presentation is similar to acute coronary syndrome and the acute course can be complicated by heart failure, arrhythmias, dynamic left ventricular outflow tract obstruction, hypotension and death. We briefly review the clinical presentation and propose a unified diagnostic algorithm for cardiologists acutely managing this cardiac emergency. We highlight the central role of echocardiography and emphasize the nuances of this peculiar acute cardiomyopathy from an echocardiographers' perspective.

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“…Echocardiography with evaluation of LVOA in terms of obstruction is crucial to the diagnosis of SAM (13). Transthoracic echocardiogram (TTE) can be used as a first line diagnostic tool (10), however, TEE is recommended if TTE is limited, especially in hemodynamically unstable patients (3).…”

Section: Discussionmentioning

confidence: 99%

Systolic anterior motion of the mitral valve—the mechanism of postural hypotension following left intrapericardial pneumonectomy

Lasala

Tsai²,

Rodríguez-Restrepo

et al. 2017

J. Thorac. Dis.

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Systolic anterior motion (SAM) is defined as displacement of the distal portion of the anterior leaflet of the mitral valve toward the left ventricular outflow tract obstruction. SAM can occur in patients without hypertrophic cardiomyopathy (HOCM) and is a well-recognized cause for unexplained sudden hypotension in perioperative settings. We present a case of persistent orthostatic hypotension caused by SAM following left intrapericardial pneumonectomy and mediastinal lymph node dissection for squamous cell carcinoma of the lung invading intrapericardial portion of the inferior pulmonary vein. Diagnosis of SAM was possible with the use of transesophageal echocardiography (TEE). J Thorac Dis 2017;9(4):E354-E357 jtd.amegroups.com utilizing 60 mm TA stapler with blue (3.5 mm) staple load. Essentially all pericardium to the left of the midline was also resected en bloc with the specimen. Since the heart was laying anatomically oriented in the left chest without any tension on the venous return, and because of the very large size of pericardial defect, the pericardium was not reconstructed. Chest cavity was closed with one drain in place connected to post pneumonectomy pleurovac.Patient remained hemodynamically stable for the first 24 hours, however, on postoperative day (POD) 2 started experiencing severe postural hypotension {81/53 [62] mmHg}, which temporarily responded to fluid boluses, and subsequently required phenylephrine infusion at 50 mcg per minute. Patient also manifested hepatojugular reflux with jugular venous distention. Right heart failure and pulmonary hypertension were considered in the differential diagnosis, and bedside transesophageal echocardiography (TEE) showed the right ventricle mildly dilated with mildly depressed right ventricular systolic function, dilation of the right atrium, and left atrium small in size. Computed tomography (CT) scan of the chest, however, demonstrated evidence of left atrial compression, suggesting dynamic obstruction of the venous return from the remaining right-sided pulmonary veins (Figure 2). Due to the patient's hemodynamic instability off of phenylephrine, the decision was made to take the patient back to the operating room for a redo thoracotomy and a pericardial reconstruction with bovine pericardium (12×25 cm bovine pericardium) on POD 4.On arrival to the operating room, patient was in the supine position and demonstrated stable hemodynamics with four liters of supplemental oxygen and phenylephrine infusion at 0.3 mcg/kg/min. A pre-induction arterial line was placed and vital signs were as follows; blood pressure 139/72 [99] mmHg, heart rate of 84 bpm, respiratory rate of 14, and oxygen saturation of 95%. After a smooth induction the patient was easily intubated with a single lumen endotracheal tube. A 9-French central line was placed in the right internal jugular vein with ultrasound guidance. Upon insertion of the central line, the patient's baseline CVP was 23 mmHg in supine position. An orogastric tube was inserted to empty and decompress the...

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Unexplained hypotension: The spectrum of dynamic left ventricular outflow tract obstruction in critical care settings*

Abstract: LVOTO should be suspected especially in women presenting with hypotension and systolic murmur in critical care settings. Clinical acumen and timely echocardiography are required to effectively counter this transient but potentially lethal problem.

Cited by 48 publications

References 13 publications

Clinical Management of Takotsubo Cardiomyopathy

Clinical Management of Takotsubo Cardiomyopathy

Echocardiography in stress cardiomyopathy and acute LVOT obstruction

Systolic anterior motion of the mitral valve—the mechanism of postural hypotension following left intrapericardial pneumonectomy

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