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Left Ventricular Outflow Obstruction


Presentation

  • CASE PRESENTATION: We present a case that displays the unique therapeutic challenges of treating a patient who developed both LVOT obstruction and mitral PVL after undergoing surgical aortic and mitral valve replacement (MVR).[ncbi.nlm.nih.gov]
  • CASE PRESENTATION: We present the case of a 65 year-old lady referred to us from a rural hospital where she was treated with thrombolytic therapy for a presumed acute anterior myocardial infarction.[ncbi.nlm.nih.gov]
  • Abstract A 66-year-old female with known mitral stenosis presented with symptoms of progressive pulmonary congestion.[ncbi.nlm.nih.gov]
  • Abstract We present a case of previously undiagnosed hypertrophic obstructive cardiomyopathy (HOCM) with left ventricular outflow obstruction in a woman anesthetized for lumbar hemilaminectomy and diskectomy.[ncbi.nlm.nih.gov]
  • A patient is described who presented with acute myocardial infarction and in whom significant left ventricular outflow tract obstruction developed.[ncbi.nlm.nih.gov]
Intravenous Administration
  • On cardiac catheterization, a left ventricular peak systolic outflow gradient of 50 mm Hg was noted; this decreased to 10 mm Hg following intravenous administration of 100 mg of cibenzoline.[ncbi.nlm.nih.gov]
Chest Discomfort
  • Abstract A 46-year-old man was admitted for further evaluation of exertional chest discomfort. One family member had experienced sudden death, and 2 others had died of heart failure, including 1 known to have had Fabry's disease.[ncbi.nlm.nih.gov]
Heart Disease
  • Echocardiography has become an integral tool in the assessment of patients with congenital heart disease.[ncbi.nlm.nih.gov]
  • Author information 1 Department of Cardiology, University Hospital Virgen de la Victoria, Malaga, Spain. fjcabrera@secardiologia.es Abstract To determine whether patients with no heart disease who develop dynamic left ventricular outflow obstruction ([ncbi.nlm.nih.gov]
  • Left ventricular outflow tract obstruction (LVOTO) is a relatively common form of congenital heart disease; it occurs in 2.8 per 10,000 births and accounts for 3 to 6 percent of congenital heart defects. 1 The levels of obstruction are classified anatomically[mhmedical.com]
  • Disease in Infants and Children; 2nd ed, Nichols et al: Left Ventricular Outflow Obstruction [2] J Thorac Cardiovasc Surg. 1966 Apr;51(4):484-92: Cornell et al: Supravalvular aortic stenosis [3] Eur J Cardiothorac Surg. 2007 Jun;31(6):1013-21: Alsoufi[dontforgetthebubbles.com]
Systolic Murmur
  • Four hours after thrombolysis she developed acute pulmonary oedema and a new systolic murmur. It was presumed she had acute mitral regurgitation secondary to a ruptured papillary muscle, ischaemic dysfunction or an acute ventricular septal defect.[ncbi.nlm.nih.gov]
  • […] anterior motion of the the mitral vale important to recognise as can contribute to a low output state that gets worse with inotropic support ASSESSMENT History hypertenison post AVR known LVH or HOCM increasing inotropes no tamponade Examination late systolic[lifeinthefastlane.com]
  • A newly detected systolic murmur in the left lower sternal border may be noticed upon physical examination; however a definitive diagnosis would require an echocardiographic examination.[kjim.org]
  • Cardiac examination revealed a Grade 2/6 cresendo-decrescendo systolic murmur heard in the left third intercostal space close to the sternum. Except for hemoglobin of 10 g%, other biochemical investigations were within normal limits.[jiaecho.org]
  • HOCM should be suspected if a harsh systolic murmur is noted in conjunction with left ventricular hypertrophy and deep, broad Q waves. Diagnosis can be confirmed by echocardiography.[openanesthesia.org]
Heart Murmur
  • Other forms of LVOTO are often asymptomatic and may be detected by the presence of a heart murmur or abnormalities on ECG. Chest pain, dyspnea, and palpitations occur with increased activity as the degree of obstruction worsens.[mhmedical.com]
  • murmurs and other sounds (Medical Encyclopedia) Patent ductus arteriosus (Medical Encyclopedia) Ventricular septal defect (Medical Encyclopedia) [ Read More ][icdlist.com]
Suggestibility
  • This article suggests that LVOT obstruction after the Senning procedure can be palliated by asynchronous septal contraction induced by AV sequential pacing, even if the activation is from LV apex, and avoid or postpone surgery in selected situations.[ncbi.nlm.nih.gov]
  • We suggest that postoperative atrial fibrillation may precipitate dynamic left ventricular outflow obstruction following mitral annuloplasty.[ncbi.nlm.nih.gov]
  • Echocardiographic and cardiac catheterization data suggest that left ventricular function need not be adversely affected by placement of a stent in the small infant ventricle; rather, ventricular function can be markedly improved.[ncbi.nlm.nih.gov]
  • This experience suggests that this approach is effective in relieving complex left ventricular outflow tract obstruction with good early results, and that it deserves more frequent application in children.[ncbi.nlm.nih.gov]
  • The sequence of our patient's presentation suggests that the apical ballooning caused geometric alterations in her left ventricle that in turn led to acute and severe mitral regurgitation, systolic anterior motion of the mitral valve and left ventricular[ncbi.nlm.nih.gov]
Confusion
  • Abstract Accessory mitral valve tissue, a rare cause of left ventricular outflow tract obstruction, can be difficult to diagnose preoperatively and confusing even at surgery.[ncbi.nlm.nih.gov]

Workup

Left Axis Deviation
  • ECG: Findings also may include right or left axis deviation, conduction abnormalities, sinus bradycardia with ectopic atrial rhythm and atrial enlargement. Voltage criteria for LVH alone are nonspecific and are often seen in normal young adults.[patient.info]

Treatment

  • Swift intervention with transesophageal echocardiography revealed the tru pathology altering her intraoperative treatment and her subsequent chronic treatment for her heart condition.[ncbi.nlm.nih.gov]
  • Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK. a.furck@rbht.nhs.uk Abstract Severe left ventricular outflow obstruction often is associated with diastolic left ventricular myocardial dysfunction and tachycardia despite successful initial treatment[ncbi.nlm.nih.gov]
  • Abstract Although percutaneous transluminal septal myocardial ablation (PTSMA) has been the established treatment of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM), the efficacy for specific HOCM is not elucidated.[ncbi.nlm.nih.gov]
  • Abstract Six patients, ranging in age from 8 to 20 years, underwent left ventricular apicoaortic construction for treatment of complicated left ventricular outflow tract obstruction.[ncbi.nlm.nih.gov]
  • The pathophysiology, treatment, and role of intraoperative echocardiography of dynamic left ventricular outflow tract obstruction are discussed.[ncbi.nlm.nih.gov]

Prognosis

  • The long-term prognosis is excellent.[ncbi.nlm.nih.gov]
  • After development of severe symptoms, NYHA functional class becomes the dominant marker of prognosis independently of the presence of an outflow gradient.[ncbi.nlm.nih.gov]
  • Untreated, this subset of patients has a poor prognosis, with one study reporting more than 50 percent to worsen symptomatically and 11 percent dying by four- year follow-up.[advances-in-medicine.net]
  • Four-year recurrence rate and prognosis of the apical ballooning syndrome. J Am Coll Cardiol 2007; 50 : 448–452. 17. Singh K, Carson K, Shah R, Sawhney G, Singh B, Parsaik A, et al.[jstage.jst.go.jp]
  • Prognosis The clinical course is variable; many remain asymptomatic throughout life but others develop severe heart failure or atrial fibrillation, or die suddenly, often at a young age and in the absence of previous symptoms.[patient.info]

Etiology

  • The majority of LVOTO (with the exception of calcific and rheumatic aortic stenosis) are congenital in etiology. Echocardiography has become an integral tool in the assessment of patients with congenital heart disease.[ncbi.nlm.nih.gov]
  • Incidence of LVOTO related to the mechanism of the mitral insufficiency and to the etiology demonstrates a direct relation to preoperative mitral valve prolapse (posterior leaflet /- anterior leaflet) of degenerative origin.[ncbi.nlm.nih.gov]
  • Keywords Adolescent — Cardiac Surgical Procedures — Child — Child, Preschool — Humans — Infant — Mitral Valve Insufficiency/complications/surgery — Reoperation — Retrospective Studies — Risk Factors — Treatment Outcome — Ventricular Outflow Obstruction/etiology[archive-ouverte.unige.ch]
  • Choi, and Kim: Dynamic left ventricular outflow tract obstruction without basal septal hypertrophy, caused by catecholamine therapy and volume depletion Abstract Hypertrophic cardiomyopathy (HCM) with hypertrophy of the basal septum is the most common etiology[kjim.org]

Epidemiology

  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • Epidemiology Left ventricular outflow tract obstruction (LVOTO) occurs in 2.8 of 10,000 live births, accounting for 3 to 6 percent of congenital heart defects.[mhmedical.com]
  • Epidemiology HCM is the most common genetic cardiovascular disease. HCM is generally inherited as an autosomal dominant trait with variable penetrance and expressivity. A minority of cases reflect a sporadic, non-familial form of the disease.[patient.info]
  • Epidemiology and clinical profile of takotsubo cardiomyopathy. Circ J 2014; 78 : 2119–2128. 33. Owa M, Aizawa K, Urasawa N, Ichinose H, Yamamoto K, Karasawa K, et al.[jstage.jst.go.jp]
Sex distribution
Age distribution

Pathophysiology

  • The pathophysiology, treatment, and role of intraoperative echocardiography of dynamic left ventricular outflow tract obstruction are discussed.[ncbi.nlm.nih.gov]
  • […] echocardiographic features predictive of latent left ventricular (LV) outflow obstruction in 50 consecutive patients with nonobstructive hypertrophic cardiomyopathy (26 provocable, 24 nonprovocable with amyl nitrite inhalation) to have a better understanding of the pathophysiology[ncbi.nlm.nih.gov]
  • It is imperative, therefore, that the pathophysiologic processes involved in DLVOTO be fully understood in order to initiate safe and appropriate therapy in critically ill patients.Our presentation and discussion focus on a hypotensive critically ill[karger.com]
  • Pathophysiology Obstruction at any level causes increased left ventricular systolic pressure and wall stress and consequent left ventricular hypertrophy. Left ventricular hypertrophy produces subendocardial ischemia and diastolic dysfunction.[mhmedical.com]
  • Stress (Takotsubo) cardiomyopathy: A novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning. Nat Clin Pract Cardiovasc Med 2008; 5 : 22–29. 28.[jstage.jst.go.jp]

Prevention

  • As such, subvalvular left ventricular outflow obstruction complicating valvular aortic stenosis is a potentially preventable cause of persistently high gradients that remains relatively frequently encountered after AVR.[ncbi.nlm.nih.gov]
  • Thus, surgical techniques to reduce AML heights should be considered in patients with disproportionately large anterior leaflets in order to prevent SAM. Selection of size of the annuloplasty ring should take into consideration the height of the AML.[ncbi.nlm.nih.gov]
  • […] exam CURRENT PHARMACY TABLES that highlight indications, toxic effects, and drug interactions sections that present TYPICAL INDICATION CLINICAL SCENARIOS EXTENSIVELY EDITED CHAPTERS on cardiology, pulmonology, nephrology, critical care, geriatrics, preventive[books.google.de]
  • Patients with multiple risk factors for sudden death benefit from implantable cardioverter defibrillator (ICD) implantation for primary prevention.[patient.info]
  • Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. European Heart Journal 2005;26:516-524. 3. Fernández A, Casabé H, Coronel R et al.[echobasics.de]

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