Is it aortic stenosis or left ventricular outflow tract obstruction? The complementary role of four-dimensional flow cardiac magnetic resonance imaging.
Is it aortic stenosis or left ventricular outflow tract obstruction? The complementary role of four-dimensional flow cardiac magnetic resonance imaging.
Project description:The authors describe a patient with hypertrophic cardiomyopathy with concomitant left ventricular outflow tract obstruction and aortic stenosis. Detailed haemodynamic assessment of the serial lesions was performed. Alcohol septal ablation resulted in a significant reduction of gradients across the left ventricular outflow tract.
Project description:We describe the first case of successful management of left ventricular outflow tract obstruction developing late after transcatheter aortic valve replacement with right ventricular apical pacing. The possible mechanisms of obstruction resolution are described. (Level of Difficulty: Advanced.).
Project description:Abstract Background Left ventricular outflow tract (LVOT) obstruction may occur with aortic stenosis (AS). However, the severity of AS is difficult to determine in this condition because the dynamic pressure gradient in LVOT obstruction influences the blood flow across the aortic valve. Case summary A 74-year-old woman was referred to our hospital having complaints of exertional dyspnoea and chest pain. Transthoracic echocardiography demonstrated LVOT obstruction with peak pressure gradient of 93 mmHg and ‘moderate’ AS with 3.9 m/s peak velocity and mean pressure gradient of 26 mmHg. Coronary angiography did not indicate any significant coronary artery disease. The pressure gradients at LVOT and aortic valve were measured as 34 mmHg and 76 mmHg via a pressure wire-pullback analysis, respectively. Intravenous 2 mg propranolol and 70 mg cibenzoline were administered to minimize the LVOT obstruction. Subsequently, these pressure gradients changed to 2 mmHg and 96 mmHg, respectively. The patient was finally diagnosed with ‘severe’ AS concomitant with LVOT obstruction. Therefore, surgical aortic valve replacement and myectomy were performed to remove the double obstruction. Discussion Herein, we present a case of ‘double’ LVOT obstruction due to dynamic myocardial component and fixed aortic component. Although the severity of AS is known to be influenced by LVOT obstruction, the present case is novel to demonstrate the phenomenon by using a pressure wire during pharmacological intervention. An accurate evaluation of the AS severity is important to provide adequate treatment. Therefore, the severity of AS should be evaluated while minimizing the LVOT obstruction.
Project description:Hemodynamically significant left ventricular outflow tract obstruction is a rare complication of transcatheter aortic valve implantation (TAVI). This study presents an unusual case of a patient who, after a successful TAVI, developed and experienced progressive worsening of severe left ventricular outflow tract obstruction after uneventful TAVI that was effectively relieved using mavacamten.
Project description:Left ventricular outflow tract obstruction is an important complication after interrupted aortic arch repair and subsequent interventions may adversely affect survival. Identification of patients at risk for obstruction is important to facilitate clinical decision-making and monitoring during follow-up. The aim of this review is to summarize reported risk factors for left ventricular outflow tract obstruction after corrective surgery for interrupted aortic arch. A systematic search of the literature was performed across the PubMed and EMBASE databases. Studies that reported echocardiographic and/or clinical predictors for left ventricular outflow tract obstruction in infants that underwent biventricular repair of interrupted aortic arch were included. From the 44 potentially relevant studies, eight studies met the inclusion criteria. Postoperative left ventricular outflow tract obstruction requiring an intervention was common, with an incidence ranging between 14 and 38%. Manifestation of postoperative left ventricular outflow tract obstruction was associated with a smaller pre-operative size of the aortic root (sinus of Valsalva), sinotubular junction, and aortic annulus. Anatomic and surgical risk factors for left ventricular outflow tract obstruction were the presence of an aberrant right subclavian artery, use of a pulmonary homograft or polytetrafluoroethylene interposition graft for aortic arch repair, and the presence of a small- or medium-sized ventricular septal defect. In patients with a borderline left ventricular outflow tract that undergo a primary repair, these (pre-) operative predictors can provide guidance for optimal surgical decision-making and for close monitoring during follow-up of patients at increased risk for developing left ventricular outflow tract obstruction after corrective surgery.
Project description:We submit a cautionary tale of a patient with critical aortic stenosis presenting with acute myocardial infarction and cardiogenic shock, who underwent balloon aortic valvuloplasty, insertion of a transvalvular left percutaneous ventricular assist device and high-risk percutaneous coronary intervention, with a post-operative course complicated by outflow obstruction from the device itself. (Level of Difficulty: Intermediate.) Central Illustration
Project description:BackgroundCardiac involvement in Fabry disease is usually characterized by left ventricular hypertrophy (LVH) without obstruction at rest.Case summaryA 59-year-old female patient with progressive chest tightness misdiagnosed as having hypertrophic cardiomyopathy due to LVH with obstruction was finally diagnosed with Fabry disease. Echocardiography showed LVH with severe obstruction, "binary sign," papillary muscle hypertrophy, and depressed longitudinal strain in the basal inferolateral region. The patient felt chest tightness worsened 1 year after receiving enzyme replacement therapy. Percutaneous endocardial septal radiofrequency ablation was performed to relieve obstruction.DiscussionIt is rare for women with Fabry disease to present with severe symptoms, but it is possible. LVH with obstruction should not be a potential point of view to relax the vigilance of Fabry disease. Percutaneous endocardial septal radiofrequency ablation may help to relieve left ventricular outflow tract obstruction in Fabry disease.Take-home messagePaying attention to echocardiographic characteristics is helpful for the identification of Fabry disease.
Project description:Left ventricular outflow tract obstruction (LVOTO) has been reported with bio-prosthetic and mechanical mitral valves (MV), though it is more common with the former. The obstruction can be dynamic or fixed. We hereby report a case of fixed LVOTO following bio-prosthetic MV replacement (MVR).