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Case report: A patient with transient sigmoid septum in takotsubo syndrome with left ventricular outflow tract obstruction.

ABSTRACT: Left ventricular outflow tract obstruction is now recognized as a common complication of takotsubo syndrome, resulting in more serious acute and long-term outcomes. We describe a case of takotsubo syndrome where a transient sigmoid septum produced left ventricular outflow obstruction and explore the mechanisms leading to this occurring. This phenomenon has not been previously described. .

SUBMITTER: Ratwatte S

PROVIDER: S-EPMC8642633 | biostudies-literature |

REPOSITORIES: biostudies-literature

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A case report of cardiogenic shock from takotsubo cardiomyopathy with left ventricular outflow tract obstruction: fundamental lessons in cardiac pathophysiology.

Project description:BackgroundA subset of patients with takotsubo cardiomyopathy will develop significant dynamic left ventricular outflow tract (LVOT) obstruction leading to cardiogenic shock. However, traditional therapies for cardiogenic shock that focus on increased inotropy and afterload reduction can be detrimental in this situation.Case summaryWe describe a 71-year-old woman who presented to the emergency department with typical, substernal chest pain found to be hypotensive with ST-elevations in the lateral leads. Coronary angiography showed no significant coronary artery disease, but a left ventriculogram demonstrated takotsubo cardiomyopathy. Right heart catheterization revealed cardiogenic shock and elevated filling pressures. Haemodynamics and symptoms worsened with the initiation of dopamine and placement of intra-aortic balloon pump but improved with the initiation of phenylephrine. Follow-up echocardiogram demonstrated dynamic LVOT obstruction with concomitant severe mitral regurgitation (MR). The patient recovered in the intensive care unit for 5 days after successful weaning of phenylephrine and initiation of low-dose beta-blocker. Repeat echocardiogram 3 weeks later showed complete resolution of apical akinesis, LVOT obstruction, and MR.DiscussionElucidating whether dynamic LVOT obstruction is contributing to cardiogenic shock physiology is paramount since the management radically differs depending on the presence or absence of obstruction. Corrective therapy focuses on reducing the LVOT gradient and includes fluid administration to improve preload, beta-blocker therapy to increase diastolic filling time, and vasopressors to raise afterload.

| S-EPMC8188875 | biostudies-literature

Recurrent takotsubo syndrome with worsening of left ventricular outflow obstruction during haemodialysis: a case report.

Project description:Background:The recurrence rate of takotsubo syndrome (TS) has been reported as 1.8% per patient-year while left ventricular outflow tract (LVOT) obstruction is comorbid in 10-25% of all instances of TS. The clinical course of recurrent TS with associated LVOT while on haemodialysis has rarely been reported. Case summary:This case report involves a 60-year-old female patient receiving regular haemodialysis who was admitted for chest pain during ballroom dancing. Four years prior, she had suffered TS, and fully recovered after the hospitalization. An emergent coronary angiogram done during the second hospitalization showed no significant stenosis, and left ventriculography demonstrated mid-apical akinesia and basal hyperkinesia. Based on these findings, we diagnosed the recurrence of TS. Later in the admission, chest pain reappeared with the start of haemodialysis. A transthoracic echocardiogram demonstrated mean pressure gradient (PG) of LVOT was 58?mmHg, with systolic anterior motion of the mitral valve and basal-wall hyperkinesia. The main aetiology for her symptoms was considered as an exacerbation of LVOT obstruction due to removing intravascular volume by haemodialysis. After starting landiolol at 3 ?g/kg/min, PG of LVOT and symptoms gradually improved with uptitration of landiolol. Finally, her chest pain resolved when mean PG of LVOT was down to 38?mmHg using 10 ?g/kg/min of landiolol. Discussion:To our knowledge, this is the first report of a recurrent TS case comorbid with LVOT obstruction while on regular haemodialysis. Landiolol, the ultrashort-acting beta-blocker, may be a promising therapeutic option for rapid recovery of increased PG due to LVOT obstruction.

| S-EPMC7180539 | biostudies-literature

An unusual cause of left ventricular outflow tract obstruction.

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).

| S-EPMC4561759 | biostudies-literature

Takotsubo syndrome complicated by cardiogenic shock due to left ventricular outflow tract obstruction, acute mitral regurgitation, and atrial fibrillation: a case report.

Project description:BackgroundAlthough Takotsubo syndrome (TTS) is generally considered a benign disease, recent reports showed the incidence of cardiogenic shock due to left ventricular outflow tract obstruction (LVOTO), mitral regurgitation (MR), and primary pump failure was estimated to be 6-20%.Case summaryA 78-year-old woman presented with chest pain and cold sweats 2 days after surgery for lung cancer. Acute coronary syndrome was suspected based on her symptoms, electrocardiography, transthoracic echocardiography (TTE), and laboratory data; thus, emergency catheterization was performed. Normal coronaries were observed, with hyperkinesis at the base of the left ventricle and akinesis at its apex, leading to the diagnosis of the apical ballooning type of TTS. Pressure differences between the apex of the left ventricle (168/8/28 mmHg) and aorta (94/50/64 mmHg) indicated the presence of LVOTO. Two days after TTS onset, she developed cardiogenic shock (blood pressure was 54/38 mmHg). Transthoracic echocardiography showed acute MR due to systolic anterior motion of the mitral valve caused by LVOTO, which was further exacerbated by paroxysmal atrial fibrillation. Fluid resuscitation, intravenous β-blockers, and amiodarone were administered for reduction of the pressure gradient in the left ventricular outflow, rate control, and sinus rhythm maintenance. Her condition improved along with the MR, thereby improving LVOTO and maintaining sinus rhythm.DiscussionTakotsubo syndrome should be kept in mind as a potential cause of acute MR due to LVOTO. Catheterization and multiple follow-up TTE play a major role in early detection for this condition.

| S-EPMC11319876 | biostudies-literature

Isolated sub-aortic obstruction - A cause of left ventricular outflow tract obstruction.

Project description: Not available

| S-EPMC10231731 | biostudies-literature

Unstable angina complicated with dynamic left ventricular outflow tract obstruction.

Project description:Left ventricular outflow tract obstruction (LVOTO) complicated with unstable angina (uAP) has not been described widely, but patients with these two conditions have several problems. Differentiation of the two conditions is also often difficult because the chest symptoms are similar. Moreover, nitrates are commonly used for ischemic heart disease, but have the effect of worsening LVOTO. We experienced three cases of dynamic LVOTO with a sigmoid-shaped septum, and without typical hypertrophic obstructive cardiomyopathy, that were complicated with uAP. In all cases, LVOTO was improved after initial percutaneous coronary intervention (PCI) for the left anterior descending artery lesion. Next, a dobutamine stress test was performed and LVOTO was provoked again in two cases, but not in a case with small acute myocardial infarction of the basal septum during PCI. All cases remained asymptomatic with beta-blocker therapy. Therefore, PCI and beta-blocker administration for LVOTO with uAP resulted in favorable clinical courses in all three cases. These outcomes suggest that revascularization including PCI should have priority in the therapeutic strategy for a case of acute coronary syndrome with LVOTO.

| S-EPMC8020068 | biostudies-literature

Dynamic Left Ventricular Outflow Tract Obstruction Exacerbated by Thoracic Kyphosis.

Project description:We present a 74-year-old woman with kyphosis and symptoms of pre/syncope. Heart catheterization revealed dynamic left ventricular outflow tract obstruction (DLVOTO) with Brockenbrough Braunwald response only when kyphotic posture was assumed. She had a positive response to metoprolol. DLVOTO is a challenging diagnosis in the absence of resting LVOTO. (Level of Difficulty: Beginner.).

| S-EPMC9911919 | biostudies-literature

Accessory mitral valve tissue that caused a left ventricular outflow tract obstruction: a case report.

Project description:BACKGROUND:Accessory mitral valve tissue (AMVT) is a rare congenital cardiac anomaly and is usually diagnosed in childhood. The diagnosis of AMVT in adulthood is extremely rare. We present a case report on an adult patient with AMVT that caused a left ventricular outflow tract (LVOT) obstruction. CASE PRESENTATION:A 51-year-old man was diagnosed with AMVT via transesophageal echocardiography, which resulted in an LVOT occlusion (mean gradient 12?mmHg) during systole. Resection of the AMVT was performed under general anesthesia. The patient was hemodynamically stable throughout the surgery and post-operation. There was no abnormity of the mitral valves, including mitral regurgitation. CONCLUSIONS:Although a very rare malformation, particularly in adults, AMVT can cause LVOT obstruction. Examination of the mitral valve using transesophageal echocardiography is important to understand the severity of LVOT obstruction.

| S-EPMC6967299 | biostudies-literature

Spatial relationship between mitral valve and ventricular septum assessed by resting echocardiography to diagnose left ventricular outflow tract obstruction in hypertrophic cardiomyopathy.

Project description:AimsEchocardiographic diagnosis of left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy (HCM) often requires extensive provocative manoeuvers. We investigated, whether echocardiography-derived parameters obtained at rest can aid to determine the presence of LVOTO in persons with HCM.Methods and resultsConsecutive patients with HCM admitted to a referral centre underwent standardized transthoracic echocardiographic examination including provocative manoeuvers. Under resting conditions, the length of mitral leaflets and distances between mitral valve coordinates and ventricular walls were blindly measured in parasternal long axis (PLAX) and apical three-chamber (3ch) views, both at early and late systole. Among 142 patients (mean age 59 ± 13 years, 42% women), 68 (42%) had resting or provocable LVOTO with maximal LVOT gradients ≥30 mmHg. Late-systolic distance between mitral leaflet tip and ventricular septum (TIS) was measurable in 137 participants (96%) in 3ch view and independently associated with LVOTO in multivariable logistic regression analysis. The area under the ROC curve of TIS for the identification of LVOTO was 0.91 [95% confidence interval (CI) 0.87-0.96]. TIS ≤ 14 mm yielded 97% sensitivity and 57% specificity regarding LVOTO. TIS >14 mm ruled out LVOTO with a negative predictive value of 95%. TIS ≤9 mm ruled in LVOTO with a positive predictive value of 92% (sensitivity 73%, specificity 95%). Among 43 patients with TIS between 10 and 14 mm, 35% had LVOTO.ConclusionIn our study, the novel echocardiographic parameter TIS showed high negative and positive predictive values for LVOTO in HCM. These exploratory results await confirmation in larger collectives and prospective investigations.

| S-EPMC10229295 | biostudies-literature

Dynamic Left Ventricular Outflow Tract Obstruction Post-Transcatheter Aortic Valve Replacement.

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.).

| S-EPMC8311343 | biostudies-literature

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