2023 SCAI SHOCK

Dynamic LVOT Obstruction Presenting with Shock

Presenter

Kaitlyn Quach, Oakland University William Beaumont School of Medicine, Auburn Hills, MI
Kaitlyn Quach1, Arvin Narula, M.D.2, Justin Parizo, M.D.3 and Brian Jaski, M.D.3, (1)Oakland University William Beaumont School of Medicine, Auburn Hills, MI, (2)San Diego Cardiac Center, San Diego, CA, (3)San Diego Cardiac Center, SHARP Memorial Hospital, San Diego, CA

Keywords: Cardiogenic Shock, Heart Failure, Hypertrophic Cardiomyopathy (HCM) and Imaging & Physiology

Title

Dynamic LVOT Obstruction Presenting with Shock

Introduction

The case is a 65 year old woman who was admitted due to cardiogenic shock and found to have Takotsubo with dynamic left ventricular obstruction. She underwent alcohol septal ablation and was discharged without any complications.

Clinical Case

A 65-year-old woman with a history of hypertension and hyperlipidemia presented to the emergency department with worsening symptoms of shortness of breath and chest pressure. She was initially hypotensive with a blood pressure of 70/59 mmHg and required BiPAP for respiratory support. Electrocardiogram (EKG) showed ST depressions in the anterior leads.

Echocardiogram: Transthoracic echocardiogram (TTE) showed an ejection fraction (EF) of 20-25% with mid apical, septal, inferior, and lateral hypokinesis. The left ventricular outflow tract (LVOT) gradient was 40 mmHg.

Cardiac catheterization: The patient was taken to the cardiac catheterization laboratory for further evaluation. The LVOT gradient was 40 mmHg at rest and increased to 170 mmHg with provocation. There was no significant coronary artery disease.

Treatment: The patient was initially managed with intravenous fluids and neosynephrine. However, her condition continued to deteriorate and she developed a dynamic LVOT gradient of 170 mmHg. The team considered mechanical circulatory support (MCS) with extracorporeal membrane oxygenation (ECMO) or Impella CP. However, the patient's condition stabilized and the team decided to proceed with alcohol septal ablation (ASA).

Alcohol septal ablation: The patient was taken back to the cardiac catheterization laboratory and 0.5 mL of dehydrated ethanol was injected into the first septal perforator. The LVOT gradient decreased to 4 mmHg post procedure.

Outcome: The patient was extubated the following day and her EF improved to 53% 48 hours later. She was discharged from the hospital on day 7 and has not had any repeat hospitalizations.

Discussion

Dynamic LVOT obstruction and Takotsubo is a rare but serious condition that can present with cardiogenic shock.

The treatment for dynamic LVOT obstruction depends on the severity of the obstruction and the underlying cause. In some cases, the obstruction can be managed with medical therapy, such as beta-blockers and calcium channel blockers. In other cases, surgery may be necessary, such as septal myectomy or alcohol septal ablation.

This case report highlights the importance of early diagnosis and treatment of dynamic LVOT obstruction. This case highlights the value of alcohol septal ablation as an acute therapy in the setting of Cardiogenic Shock and takotsubo with LVOT obstruction.