P1715 Aortic stenosis with concomitant LVOTO: an alternative treatment to surgery
Abstract The dilemma of the patient with both aortic stenosis (AS) and significant left ventricular outflow tract obstruction (LVOTO) is usually managed through conventional surgery. Patients included in TAVI studies are highly selected, and the presence of LVOTO is a common exclusion criteria. Permanent pacing is referred as a possible treatment in medically refractory symptomatic patients with obstructive hypertrophic cardiomyopathy. We report a case of AS and LVOTO that was submitted to transcatheter aortic valve replacement (TAVR) due to high surgical risk, and submitted to a definitive pacemaker implantation after the procedure. This case is about a female patient with 82 years old and a history of a severe aortic stenosis with a significant ventricular hypertrophy that causes LVOTO. She had a previous history of hypertension, dyslipidemia, osteoporosis and breast cancer. The patient presented with angina (grade II in Canadian Cardiovascular Society Angina Grade), dyspnea and weakness (classe II of New York Heart Association functional classification). Transthoracic Echocardiography (TTE) presented with severe aortic stenosis with a basal septal ventricular hypertrophy of 18 millimeters, a systolic anterior motion of the mitral valve (SAM) both conditioning LVOTO (maximal gradient of 75 mmHg at rest) and moderate mitral regurgitation (MR). Coronariography showed no coronary lesions. Transfemoral TAVR was successfully implanted under general anesthesia and transesophageal echocardiography monitoring (TOE). During ballooning pre-dilatation a complete atrioventricular block developed. Immediately after the valve implantation TOE showed a well-positioned prothesis without intra or peri-prosthetic regurgitation but with an intraventricular gradient (IVG) above 50mmHg and a moderate to severe MR. SAM, IVG and MR were medically managed and the patient went to the intensive cardiac unit (ICU) with a IVG of 50mmHg and a moderate MR. In the next 24H in the ICU, the patient had a clinical deterioration and TTE found an increased intraventricular gradient (140 mmHg) and a severe mitral regurgitation. It was decided to implant a Dual Chamber pacemaker (DDD PM) and adjust beta-blocker and fluid therapy. A progressive clinical improvement was observed and clinical stabilization attained after 48H. At discharge (7 days after TAVR), TTE showed decreased intraventricular gradients (30 mmHg at rest, 50 mmHg with Valsalva maneuver), telesystolic SAM and a moderate mitral regurgitation. At 6 moths follow up, patient was free of cardiovascular events and had no symptoms of heart failure. This case shows that TAVR is a safe procedure in patients with LVOTO, but we have to be aware of potentially severe hemodynamic consequences of sudden reduce in after load pressure in these patients. In high risk surgical patients, DDD-PM can accomplish acute and at least medium term clinical and hemodynamic stabilization. Abstract P1715 Figure. Echocardiography images