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Chraibi H, Bakamel L, Fellat R, Bendagha N, Moughil S. Conservative Management of Suicide Left Ventricle After Surgical Aortic Valve Replacement. Cureus 2023; 15:e42890. [PMID: 37664339 PMCID: PMC10474785 DOI: 10.7759/cureus.42890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Suicide left ventricle (SLV) remains an underdiagnosed cause of haemodynamic compromise following surgical or transcatheter aortic valve replacement (AVR). Risk factors include female sex and a small left ventricular cavity with asymmetric septal hypertrophy. We present the case of a 63-year-old woman, with a medical history of diabetes mellitus, arterial hypertension and dyslipidaemia who was diagnosed with severe aortic stenosis with normal left ventricular ejection fraction and concentric hypertrophy. She underwent surgical AVR using a bioprosthetic valve, but a few hours after surgery, she developed sudden cardiogenic shock. An urgent transthoracic echocardiogram was performed showing marked systolic anterior motion of the mitral valve resulting in severe dynamic left ventricular outflow tract obstruction and intraventricular gradient. The diagnosis of SLV was made. The patient was managed conservatively with volume loading and oral beta-blockers and her haemodynamic state improved gradually. She was then discharged after favourable evolution. Medical management of SLV includes volume loading to expand the ventricular volume and beta-blockers for their negative inotrope effect. When medical therapy fails, surgical myectomy or alcohol septal ablation can be proposed to remove the obstacle. Some authors have proposed these procedures as prophylactic measures to prevent SLV in high-risk patients.
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Affiliation(s)
- Hamza Chraibi
- Cardiology A Department, Ibn Sina Hospital, Mohammed V University, Rabat, MAR
| | - Lamyaa Bakamel
- Cardiology A Department, Ibn Sina Hospital, Mohammed V University, Rabat, MAR
| | - Rokya Fellat
- Cardiology A Department, Ibn Sina Hospital, Mohammed V University, Rabat, MAR
| | - Nesma Bendagha
- Cardiology A Department, Ibn Sina Hospital, Mohammed V University, Rabat, MAR
| | - Said Moughil
- Cardiovascular Surgery B Department, Ibn Sina Hospital, Mohammed V University, Rabat, MAR
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Barasch E. Aortic Stenosis Associated with Hypertrophic Cardiomyopathy: A Double Trouble. Cardiology 2023; 148:287-288. [PMID: 37062287 DOI: 10.1159/000530663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 03/30/2023] [Indexed: 04/18/2023]
Affiliation(s)
- Eddy Barasch
- Department of Research and Education, St. Francis Hospital, the Heart Center/SUNY at Stony Brook, Roslyn, New York, USA
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Ben-Dor I, Rogers T, Medranda GA, Medvedofsky D, Weissman G, Case BC, Satler LF, Waksman R. A Word of Caution Before Treating Aortic Stenosis in Patients With Concomitant LVOT Obstruction. JACC Case Rep 2022; 4:1162-1168. [PMID: 36213885 PMCID: PMC9537090 DOI: 10.1016/j.jaccas.2022.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/07/2022] [Accepted: 01/21/2022] [Indexed: 12/04/2022]
Abstract
Patients with aortic stenosis and concomitant left ventricular outflow tract obstruction undergoing transcatheter aortic valve replacement are at risk of hemodynamic collapse after the procedure due to worsening left ventricular outflow tract obstruction. We present 3 cases highlighting the important interplay between these 2 disease states and associated diagnostic and treatment challenges. (Level of Difficulty: Advanced.)
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Non-surgical management of an acute decompensated heart failure patient with severe aortic stenosis and concomitant left ventricular outflow tract obstruction. J Cardiol Cases 2022; 25:188-192. [PMID: 35261708 PMCID: PMC8888729 DOI: 10.1016/j.jccase.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/20/2021] [Accepted: 09/10/2021] [Indexed: 11/23/2022] Open
Abstract
Acute decompensated heart failure (ADHF) due to severe aortic stenosis (AS) and concomitant left ventricular outflow tract (LVOT) obstruction is a serious condition. Treatment with medication alone is sometimes difficult, and the efficacy of further interventional strategies has not been fully elucidated. In patients with high surgical risks, combination therapy using transcatheter aortic valve replacement (TAVR) and percutaneous alcohol septal ablation (ASA) is used as a non-surgical intervention. However, this treatment cannot be performed under unstable hemodynamic conditions. This report highlights the utility and efficacy of emergent balloon aortic valvuloplasty (BAV) in controlling heart failure and its potential to serve as a bridge to curative therapy, even in older patients with ADHF due to severe AS with concomitant LVOT obstruction. Furthermore, combination therapy with TAVR and percutaneous ASA could be safely performed after controlling for ADHF using BAV. Non-surgical management is a more feasible treatment option in older patients with ADHF who are at higher risk of complications during surgical intervention. <Learning objective: Management of acute decompensated heart failure (ADHF) due to severe aortic stenosis (AS) and concomitant left ventricular outflow tract (LVOT) obstruction can be difficult. Despite concomitant LVOT obstruction, emergent balloon aortic valvuloplasty is potentially useful and effective for controlling heart failure and could become a bridge to subsequent combination therapy using transcatheter aortic valve replacement and percutaneous alcohol septal ablation. This sequential non-surgical management is a novel strategy for older patients with high surgical risk and ADHF due to severe AS with concomitant LVOT obstruction.>
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Lioufas PA, Kelly DN, Brooks KS, Marasco SF. Unexpected suicide left ventricle post-surgical aortic valve replacement requiring veno-arterial extracorporeal membrane oxygenation support despite gold-standard therapy: a case report. Eur Heart J Case Rep 2022; 6:ytac020. [PMID: 35233483 PMCID: PMC8874837 DOI: 10.1093/ehjcr/ytac020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/31/2021] [Accepted: 12/30/2021] [Indexed: 11/16/2022]
Abstract
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 transcatheter 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 SAVR and a MAZE procedure. There were no significant signs of ventricular hypertrophy on preoperative transthoracic echocardiogram (TTE). Intraoperatively, there was mild chordal systolic anterior motion of the mitral valve (SAM) which only occurred when underfilled. During recovery in the intensive care unit, the patient’s pulmonary arterial pressures were noted to rise with worsening cardiac output. Subsequent TTE showed severe dynamic left ventricular outflow tract (LVOT) 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 veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support was initiated. Following 72 h 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 postoperatively should be investigated rapidly with echocardiography. Furthermore, resolution of a LVOT obstruction state from procedural intervention may not immediately follow with improved cardiac output, and may require further supportive management.
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Affiliation(s)
- Peter Andrew Lioufas
- Department of Intensive Care, Epworth Richmond, Ground Floor, 89 Bridge Road, Richmond, Victoria 3121, Australia
| | - Diane N Kelly
- Department of Intensive Care, Epworth Richmond, Ground Floor, 89 Bridge Road, Richmond, Victoria 3121, Australia
- Department of Intensive Care, The Royal Melbourne Hospital, Level 5 Building B, 300 Grattan Street, Parkville, Victoria 3050, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, 27 Rainforest Walk, Clayton, Victoria 3800, Australia
| | - Kyle S Brooks
- Department of Intensive Care, Epworth Richmond, Ground Floor, 89 Bridge Road, Richmond, Victoria 3121, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Building 104, Alan Gilbert Building, University of Melbourne, 161 Barry Street, Carlton, Victoria 3010, Australia
| | - Silvana F Marasco
- Department of Cardiothoracic Surgery, Epworth Richmond, Epworth Centre, Suite 8.6, 32 Erin Street, Richmond, Victoria 3121, Australia
- Department of Cardiothoracic Surgery and Transplantation, The Alfred Hospital, Commercial Road, Melbourne, Victoria 3004, Australia
- Department of Surgery, Monash University, The Alfred Hospital, Central Clinical School, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, Victoria 3004, Australia
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Alkhouli M, Eleid MF, Nishimura RA, Rihal CS. The Role of Invasive Hemodynamics in Guiding Contemporary Transcatheter Valvular Interventions. JACC Cardiovasc Interv 2021; 14:2531-2544. [PMID: 34887047 DOI: 10.1016/j.jcin.2021.08.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/02/2021] [Accepted: 08/08/2021] [Indexed: 11/17/2022]
Abstract
Recent advances in transcatheter interventions have refueled the interest in utilizing invasive hemodynamics in the catheterization laboratory. The authors review contemporary invasive techniques used to confirm valve disease and guide transcatheter valve interventions. They also discuss the available data and the remaining questions on the role of invasive hemodynamics in current practice and in the future.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Li Y, Feng Y, Li X, Zuo L, Gu T, Liu L, Chen M. Case Report: Minimally Invasive Therapy by Transcatheter Aortic Valve Replacement and Percutaneous Intramyocardial Septal Radiofrequency Ablation for a Patient With Aortic Stenosis Combined With Hypertrophic Obstructive Cardiomyopathy: Two-Year Follow-Up Results. Front Cardiovasc Med 2021; 8:735219. [PMID: 34616787 PMCID: PMC8488101 DOI: 10.3389/fcvm.2021.735219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/23/2021] [Indexed: 02/05/2023] Open
Abstract
With the development of minimally invasive technologies in the medical field, more and more technologies can replace surgical thoracotomy and relieve the pain of disease via minimally invasive methods. We reported a case of aortic valve stenosis combined with left ventricular outflow track obstruction treated by two minimally invasive techniques, transcatheter aortic valve replacement and transthoracic echocardiography–guided percutaneous intramyocardial septal radiofrequency ablation, and followed up for 2 years.
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Affiliation(s)
- Yijian Li
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Yuan Feng
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Xi Li
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Lei Zuo
- Department of Ultrasound, Xijing Hypertrophic Cardiomyopathy Center, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Tao Gu
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Liwen Liu
- Department of Ultrasound, Xijing Hypertrophic Cardiomyopathy Center, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Mao Chen
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
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Bode MF, Ahmed AA, Baron SJ, Labib SB, Gadey G. The use of MitraClip to prevent posttranscatheter aortic valve replacement left ventricular "suicide". Catheter Cardiovasc Interv 2020; 97:369-372. [PMID: 32589359 DOI: 10.1002/ccd.29100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/20/2020] [Accepted: 06/05/2020] [Indexed: 11/08/2022]
Abstract
Patients with concomitant severe aortic stenosis (AS) and left ventricular outflow tract (LVOT) obstruction undergoing transcatheter aortic valve replacement (TAVR) are at risk for hemodynamic collapse due to a sudden decrease in afterload causing worsening LVOT obstruction. We present a case of an 88-year-old female with symptomatic, severe AS, and LVOT obstruction with systolic anterior motion (SAM) of the mitral leaflet in whom alcohol septal ablation was contraindicated secondary to a chronic total occlusion of the right coronary artery that filled retrograde via septal collaterals. MitraClip at the time of TAVR was successfully performed to treat SAM with subsequent stabilization of LVOT gradients despite treatment of the patient's AS. This novel approach may represent a feasible option to prevent hemodynamic complications after TAVR in patients with significant LVOT obstruction secondary to SAM and AS.
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Affiliation(s)
- Michael F Bode
- Division of Cardiology, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Andaleeb A Ahmed
- Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Suzanne J Baron
- Division of Cardiology, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Sherif B Labib
- Division of Cardiology, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Gautam Gadey
- Division of Cardiology, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
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Rowin EJ, Kimmelstiel C. Combined alcohol septal ablation and transcatheter aortic valve replacement: Drunk and playing with fire. Catheter Cardiovasc Interv 2020; 95:838-839. [PMID: 32159290 DOI: 10.1002/ccd.28795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/13/2020] [Indexed: 11/10/2022]
Abstract
Evaluation of the severity of aortic stenosis in the presence of dynamic left ventricular outflow (LVOT) obstruction is challenging. Invasive hemodynamic assessment with provocative maneuvers can be useful to differentiate of the relative components of obstruction. In patients with both dynamic LVOT obstruction and aortic stenosis, surgical myectomy and concurrent surgical aortic valve replacement is the optimal treatment strategy; combined alcohol septal ablation and transcatheter aortic valve replacement should only be considered for very high surgical risk patients.
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Affiliation(s)
- Ethan J Rowin
- Hypertrophic Cardiomyopathy Institute, Tufts Medical Center, Boston, Massachusetts
| | - Carey Kimmelstiel
- Hypertrophic Cardiomyopathy Institute, Tufts Medical Center, Boston, Massachusetts.,Cardiac Catheterization Laboratory, Tufts Medical Center, Boston, Massachusetts
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