Dynamic LVOT obstruction

Sherif M Helmy, MD, FASE

Sr Consultant of Cardiology
Heart Hospital, HMC, Qatar

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

“Speaker disclosure - I do not have an affiliation (financial or
otherwise) with a pharmaceutical, medical device, or
communication and event planning company.”

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Dynamic LV Outflow Tract Obstruction
Outline
• Introduction
• DLVOTO in HCM
• Causes of DLVOTO other than HCM
• Case studies
• Conclusions

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Dynamic LV Outflow Tract Obstruction
Definition

Obstruction to the LVOT by structural abnormalities

which can be provoked or altered by a change in the

physiological conditions.

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Dynamic LV Outflow Tract Obstruction
Introduction
• Dynamic LVOT obstruction has been associated with HCM.
• Recently it was noted that it also occurs in numerous diseases
and may be found absence of a noticeable cardiac disease
(<1% cases).
• It is usually transient and accompany certain clinical situations.
• It is one of the more common causes of unexplained
hypotension.
• The diagnosis of LVOTO is important to eliminate the factors
that can potentially intensify the obstruction.
Sherif M Helmy, MD, FASE, ICU, Qatar 2019
 Hallmarks of Dynamic LV Outflow Tract Obstruction

• Obstruction occurs in mid to

late systole > Dagger shaped
Doppler signal
• Associated with SAM
• Posteriorly directed MR jet
• Mid systolic closure of the
aortic cusps
• Provoked by or altered by
loading conditions

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Hallmarks of dynamic LVOT obstruction

Fixed obstruction Dynamic obstruction

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Hallmarks of Dynamic LV Outflow Tract Obstruction

SAM Mid systolic notch of the aortic cusps

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 HCM

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Cardiomyopathy: Definition

● “A myocardial disorder in which the heart muscle is

structurally and functionally abnormal, in the absence of
coronary artery disease, hypertension, valvular disease
and congenital heart disease sufficient to cause the
observed myocardial abnormality.”

ESC Working Group on Myocardial Pericardial Diseases (Elliott P et al. EHJ 2007)

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 HCM: Definitions

Increased left ventricular wall thickness not solely explained by

abnormal loading conditions

ADULTS:
●LV wall thickness ≥15 mm in one or more LV myocardial segments
measured by any imaging technique

CHILDREN:
●LV wall thickness more than two standard deviations above the predicted
mean (z-score >2)

European Heart Journal (2014):doi:10.1093/eurheartj/ehu284

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Case 1
HOCM

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Differential diagnosis of unexplained LV hypertrophy

ASE’s comprehensive Echocardiography, 2015

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Multimodality approach for the diagnosis of unexplained LVH

ASE’s comprehensive Echocardiography, 2015

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Clinical History: Differential Diagnosis of LVH

Hypertension Hypertensive heart disease

Multiple myeloma or chronic Cardiac amyloidosis

Clinical inflammatory disease
History
Neurological problems related to ataxia Freidreich’s cardiomyopathy

Multiple organ involvements (kidneys Fabry’s disease

or nervous system)

Weidman et al, JASE, 2010;23, 791-801

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Echocardiography strain analysis: Differential Diagnosis of LVH
Interpret images in context
of clinical features and
other tests:
A: HCM
B: Normal
C: Amyloidosis
D: Fabry’s
E: Non compacation

ASE’s comprehensive Echocardiography, 2015

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

Physiological variants of HCM

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Case 2
Mild septal hypertrophy with SAM……419689

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Dynamic LVOTO in HCM develops due to

• structural defects:
Narrowing by septal hypertrophy;

THAT IS NOT THE WHOLE

STORY
• Hydrodynamic forces causing SAM

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Dynamic LVOTO in HCM develops due to

• Multiple structural defects:

a) Narrowing by septal hypertrophy;
b) Mitral leaflets abnormalities;
c) anterior displacement of the MV apparatus;
d) anterior malposition of the papillary muscles.
• Hydrodynamic forces causing SAM

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

Diverse geometric changes related to DLVOTO

• In hypertrophic cardiomyopathy patients without

significant LV hypertrophy, in addition to basal septal
thickness, anterior MV length, abnormal chordal
attachment, and bifid PM mobility are associated with
LVOT obstruction. In such patients, additional procedures
on MV and PM (±myectomy) could be considered.

Patal et al., Circ Cardiovasc Imaging. 2015;8:e003132. DOI: 10.1161/CIRCIMAGING.115.003132.)

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

Sherif M Helmy, MD, FASE, ICU, Qatar 2019
 Case 3:
Accessory mitral valve tissue (AMVT)

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Differential diagnosis of SAM

• Hypercontractile states (post operative inotropes)

• Post MV repair
• Anomalous papillary muscle insertion
• Anteroapical MI
• Elderly with sigmoid septum and hyperdynamic LV function
• Takotsubo cardiomyopathy

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Other than HOCM causes of DLVOTO
• Complicating acute MI
• Catecholamine excess
• Exercise overload
• Anorexia
• Dehydration
• Concentric LV hypertrophy
• After AVR of AS
• After MV repair
• Tako – tsubo ( approx. 20 %)
• Amyloidosis
• Anaemia
• After anaesthesia for non- cardiac surgery

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 CASE 4a
Acute MI

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Dynamic LVOTO as a complication of acute MI

• Numerous reports have high lightened the occurrence of transient

dynamic LVOTO as a complication of AMI
• Incidence is unclear (probably under diagnosed).
• 20 cases have been reported to 2015 (7 LAD, 7 no LAD, 6 no CAG).
• Mimic cardiogenic shock in an acute care setting
• Potentially reversible complication
• Cases experiencing myocardial rupture and death were reported

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

Pathogenesis of dynamic LVOTO as a complication of acute MI

Chockalingam et al LV Outflow Obstruction in MI, Circulation 2007

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

Management algorithm for LVOTO in acute MI

Chockalingam et al LV Outflow Obstruction in MI, Circulation 2007

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

Outline of LVOTO in AMI Precipitating Factors and Interventions

LVOTO Precipitating Factors Suggested Interventions

Basal Hyper contracatility -B blockers;
-nondihydropyridine calcium blockers
Apical dysfunction Urgent revascularization: PCI, thrombolysis
Hypotension IV fluids
phenyepherine
SAM Avoid/discontinue
Inotropes
IABP
Nitrates
Diuretics
Chockalingam et al LV Outflow Obstruction in MI, Circulation 2007

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Dynamic LVOTO as a complication of acute MI

• Clinical suspicion, early recognition, and appropriate

management of LVOTO, along with the independent addressing
of STEMI, would significantly improve the outcome in this
critically ill patient subset.
• Withdrawing inotropes and initiating intravenous b-blockers
usually improves hypotension and reduced the LVOTO
gradient.

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Case 5
Takotsubo
• Takotsubo cardiomyopathy is an increasingly recognized clinical
syndrome.
• Dynamic LVOT obstruction occurs in ~ 20% of those cases.
• The typical patient is an elderly, hypertensive female with
sigmoid deformity of the intraventricular septum.

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Case 5
Takotsubo
• Dynamic LVOT obstruction should be considered in patients
presenting with persistent hypotension or shock.
• Diagnosis of dynamic LVOT obstruction is essential to prevent
institution of potentially detrimental therapies.
• Treatment consists of fluid resuscitation and beta blockers.
• Prognosis is good and does not seem to differ from takotsubo
patients without LVOT obstruction. R

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Takotsubo
a case presentation ….

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Case 6
DSE

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

Dynamic LVOTO during stress echocardiography
Systolic velocity > 2.5 m/sec (25 mm
Definition Hg) across the LVOT with stress
Dobutamine: up to 21 %
Incidence Exercise : up to 13 %

May explain exertional dyspnea and

angina in absence of ischemia and
Significance with normal coronary angiography.
Not related to hypotension or CAD.
Elderly, females, hypertensive,
Patient characteristics diastolic dysfunction, small LV,
^RWT, LVOT<19mm/m2
References Pellika et al., 1992
Cabrera Bueno et al., 2004
Park SM et al., 2015

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

Mechanisms of left ventricular outflow tract obstruction during
hypovolemia

Ganesan G, Govindaraj A, Sangareddi V.

Transient dynamic left ventricular outflow tract obstruction. J Indian Acad Echocardiogr Cardiovasc
Imaging 2017;1:154-7.

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Case 7
MV repair 13082
• 63 y lady, DM type2, Hypertension, mild CAD, ESRD on
regular hemodialysis.
• Shortness of breath and fatigue

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 CMR

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

 Summary

• LVOT obstruction is a dynamic phenomenon

• Its occurrence requires the coexistence of predisposing
anatomic factors and a physiological condition that induces it.
• Diagnosis of LVOT obstruction should entail immediate
implementation of the therapy to eliminate the factors that
can potentially intensify the obstruction.
• Echocardiography is the basic modality in its diagnosis and
treatment.

Sherif M Helmy, MD, FASE, ICU, Qatar 2019

Sherif M Helmy, MD, FASE, ICU, Qatar 2019