scholarly journals Postural Tachycardia Syndrome and Vasovagal Syncope: A Hidden Case of Obstructive Cardiomyopathy without Severe Septal Hypertrophy

2018 ◽  
Vol 2018 ◽  
pp. 1-4
Author(s):  
Kenneth A. Mayuga ◽  
Natalie Ho ◽  
Robert W. Shields ◽  
Paul Cremer ◽  
L. Leonardo Rodriguez
Keyword(s):  
Mitral Valve ◽  
Papillary Muscle ◽  
Vasovagal Syncope ◽  
Left Ventricular ◽  
Postural Tachycardia Syndrome ◽  
Tilt Table Test ◽  
Tilt Table ◽  
Septal Myectomy ◽  
Postural Tachycardia ◽  
Septal Hypertrophy

A 36-year-old female with symptoms of orthostatic intolerance and syncope was diagnosed with vasovagal syncope on a tilt table test and with postural tachycardia syndrome (POTS) after a repeat tilt table test. However, an echocardiogram at our institution revealed obstructive cardiomyopathy without severe septal hypertrophy, with a striking increase in left ventricular outflow tract gradient from 7 mmHg at rest to 75 mmHg during Valsalva, with a septal thickness of only 1.3 cm. Cardiac MRI showed an apically displaced multiheaded posteromedial papillary muscle with suggestion of aberrant chordal attachments to the anterior mitral leaflet contributing to systolic anterior motion of the mitral valve. She underwent surgery with reorientation of the posterior medial papillary muscle head, resection of the tethering secondary chordae to the A1 segment of the mitral valve, chordal shortening and tacking of the chordae to the A1 and A2 segments of the mitral valve, and gentle septal myectomy. After surgery, she had significant improvement in her prior symptoms. To our knowledge, this is the first reported case of obstructive cardiomyopathy without severe septal hypertrophy with abnormalities in papillary muscle and chordal attachment, in a patient diagnosed with vasovagal syncope and POTS.

scholarly journals COVID-19 and postural tachycardia syndrome: a case series

2021 ◽  
Vol 5 (12) ◽  
Author(s):  
William H Parker ◽  
Rohit Moudgil ◽  
Robert G Wilson ◽  
Adriano R Tonelli ◽  
Kenneth A Mayuga ◽  
...  
Keyword(s):  
Case Series ◽  
Supportive Therapy ◽  
Collegiate Athletes ◽  
Left Ventricular ◽  
Response To Treatment ◽  
Postural Tachycardia Syndrome ◽  
Baseline Heart Rate ◽  
Tilt Table ◽  
Presenting Symptoms ◽  
Postural Tachycardia

Abstract Background Postural tachycardia syndrome (PTS) is a novel identified sequela of COVID-19 infection. This observational study describes clinical presentation, testing, and treatment response in seven patients diagnosed with PTS following COVID-19 infection. Case summary A total of seven active patients (three collegiate athletes, one recreational athlete, two registered nurses, one hospitality employee), age 24 ± 6 years, and six females were followed for a mean of 152 ± 105 days after contracting COVID-19. Tilt table was performed to establish the diagnosis. The most common presenting symptoms were palpitations (7/7), dyspnoea (6/7), and gastrointestinal complaints (5/7). One patient required hospitalization for symptom management. The mean latency of PTS onset following COVID-19 was 21 ± 15 days. Electrocardiograms (ECGs) demonstrated sinus rhythm in all patients, one with resting sinus tachycardia. Echocardiogram demonstrated normal systolic and diastolic left ventricular function in all patients. On tilt table testing, baseline heart rate (HR) was 72 ± 12 with maximum HR reaching 136 ± 13. Six of seven patients failed to respond to supportive therapy alone, and two patients failed medical management with ivabradine, midodrine, and/or metoprolol. Of three severely symptomatic patients, two demonstrated some degree of clinical recovery with intravenous immunoglobulin (IVIG). Discussion This novel case series describes the development of PTS in the context of COVID-19 infection. Severity of symptoms and response to treatment was heterogeneous. Interestingly, patients were poorly responsive to traditional PTS treatments, but IVIG showed potential as a possible therapeutic strategy for refractory PTS in two patients, particularly following COVID-19 infection.

Insights From In-Vitro Flow Visualization Into the Mechanism of Systolic Anterior Motion of the Mitral Valve in Hypertrophic Cardiomyopathy Under Steady Flow Conditions

1992 ◽  
Vol 114 (3) ◽  
pp. 406-413 ◽  
Author(s):  
X. P. Lefebvre ◽  
A. P. Yoganathan ◽  
R. A. Levine
Keyword(s):  
Mitral Valve ◽  
Flow Field ◽  
Flow Visualization ◽  
Papillary Muscle ◽  
Left Ventricular ◽  
Outflow Tract ◽  
Papillary Muscles ◽  
Systolic Anterior Motion ◽  
Septal Hypertrophy

Hypertrophic obstructive cardiomyopathy is a heart disease characterized by a thickened interventricular septum which narrows the left ventricular outflow tract, and by systolic anterior motion (SAM) of the mitral valve which can contact the septum and create dynamic subaortic obstruction. The most common explanation for SAM has been the Venturi mechanism which postulates that septal hypertrophy, by narrowing the outflow tract, produces high velocities and thus low pressure between the mitral valve and the septum, causing the valve leaflets to move anteriorly. This hypothesis, however, fails to explain why SAM often begins early in systole, when outflow tract velocities are low or negligible or why it may occur in the absence of septal hypertrophy. The goal of this study was therefore to investigate an alternative hypothesis in which structural abnormalities of the papillary muscles act as a primary cause of SAM by altering valve restraint and thereby changing the geometry of the closed mitral apparatus and its relationship to the surrounding flow field. In order to test this hypothesis, an in vitro model of the left ventricle which included an explanted human mitral valve with intact chords and papillary muscle apparatus was constructed. Flow visualization was used to observe the ventricular flow field and the mitral valve geometry. Displacing the papillary muscles anteriorly and closer to each other, as observed clinically in patients with cardiomyopathy and obstruction produced SAM in the absence of septal hypertrophy. Flow could be seen impacting on the upstream (posterior) surface of the leaflets; such flow is capable of producing form drag forces which can initiate and maintain SAM. In contrast, increasing septal hypertrophy to narrow the outflow tract and create velocities as high as 3.3 m/s did not produce SAM in the absence of papillary muscle displacement, despite an increase in the calculated lift forces. Therefore, primary abnormalities of the papillary muscle-mitral valve apparatus can alter the relationship of the mitral valve to the surrounding flow field in such a way that SAM is generated, whereas the Venturi mechanism, induced by septal hypertrophy alone, is insufficient to do so with a normally positioned and tethered valve.

scholarly journals Surgery for Hypertrophic Obstructive Cardiomyopathy: Comprehensive LVOT Management beyond Septal Myectomy

2021 ◽  
Vol 10 (19) ◽  
pp. 4397
Author(s):  
Alessandro Affronti ◽  
Robert Pruna-Guillen ◽  
Elena Sandoval ◽  
Daniel Pereda ◽  
Jorge Alcocer ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Left Ventricular Outflow Tract ◽  
Surgical Techniques ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Systolic Anterior Motion ◽  
Septal Myectomy ◽  
Left Ventricular Outflow ◽  
Septal Hypertrophy

Hypertrophic cardiomyopathy (HCM) is a complex, underestimated, multifaceted disease frequently associated with left ventricular outflow tract (LVOT) obstruction. It is clearly demonstrated that this is due not only to septal hypertrophy but also to systolic anterior motion (SAM) of mitral valve leaflets secondary to mitral valve/subvalvular apparatus abnormalities. Surgical treatment involves performing an extended septal myectomy, eventually followed by ancillary procedures to those structures responsible for maintaining LVOT obstruction, if necessary. In this review, we describe the spectrum of possible surgical techniques beyond septal myectomy and their pathophysiologic rationale.

Modified Septal Myectomy Using a Curved Knife for Left Ventricular Septal Hypertrophy

2014 ◽  
Vol 17 (5) ◽  
pp. 269
Author(s):  
Shinya Takahashi ◽  
Taiichi Takasaki ◽  
Futoshi Tadehara ◽  
Takahiro Taguchi ◽  
Keijiro Katayama ◽  
...  
Keyword(s):  
Blood Flow ◽  
Chest Pain ◽  
Aortic Valve ◽  
Cross Section ◽  
Left Ventricular ◽  
Chest Discomfort ◽  
Septal Myectomy ◽  
Asymmetric Septal Hypertrophy ◽  
Septal Hypertrophy ◽  
Septal Myocardium

An 86-year-old woman presented with chest pain and discomfort. Echocardiography revealed severe aortic valve stenosis and asymmetric septal hypertrophy. Aortic valve replacement and myectomy were performed using a curved knife. The blade was U-shaped in cross-section, and was curved upward along the long axis. Hypertrophic septal myocardium was removed along the long axis of the left ventricle (LV), and a groove for blood flow was constructed. The patient was discharged uneventfully without recurrence of her chest discomfort. Our result suggested that a curved knife is a reasonable option for transaortic septal myectomy in patients with obstructive LV hypertrophy.

Robotic Septal Myectomy Without Anterior Leaflet Incision during Mitral Valve Repair

2019 ◽  
Vol 14 (3) ◽  
pp. 281-285 ◽  
Author(s):  
Burak Onan ◽  
Ersin Kadirogullari ◽  
Zeynep Kahraman ◽  
Onur Sen
Keyword(s):  
Mitral Valve ◽  
Mitral Valve Repair ◽  
Ventricular Outflow Tract ◽  
Left Ventricular ◽  
Da Vinci Surgical System ◽  
Systolic Anterior Motion ◽  
Anterior Leaflet ◽  
Valve Repair ◽  
Septal Myectomy ◽  
Mitral Repair

Bulging subaortic septum in hypertrophic cardiomyopathy is a potential risk factor for systolic anterior motion after mitral valve repair. Systolic anterior motion may cause postoperative mitral regurgitation and left ventricular outflow tract obstruction despite conservative management. During “minimally invasive endoscopic” and “robotic” mitral repair procedures, systolic anterior motion is prevented with concomitant septal myectomy through the mitral valve orifice. Technically, the exposure of the bulging subaortic septum is traditionally done with detachment of the anterior mitral leaflet from its annulus, leaving a 2-mm rim of leaflet attached to the annulus. The leaflet is then sutured after myectomy. As an alternative technique in robotic surgery, the exposure of the subaortic septum is feasible without anterior leaflet incision with the use of dynamic atrial retractor in mitral repair procedures. Here, we present a patient who underwent concomitant robotic mitral valve repair with posterior chordal implantation, ring annuloplasty, and septal myectomy without anterior leaflet incision using the da Vinci surgical system.

scholarly journals Comparison of cortisol levels in patients with vasovagal syncope and postural tachycardia syndrome

2021 ◽  
Vol 38 (1) ◽  
Author(s):  
Humaira Fayyaz ◽  
Shazadi Ambreen ◽  
Hammad Raziq ◽  
Azmat Hayyat
Keyword(s):  
Vasovagal Syncope ◽  
Serum Cortisol ◽  
Tilt Test ◽  
Control Group ◽  
Postural Tachycardia Syndrome ◽  
P Value ◽  
Cross Sectional ◽  
Postural Tachycardia ◽  
Significant Difference ◽  
Cortisol Levels

Objectives: To compare the levels of cortisol in patients of vasovagal syncope (VVS) and postural tachycardia syndrome (POTS). Methods: A cross-sectional analytical study was conducted at Islamic International Medical College, Rawalpindi and Electrophysiology Department at (AFIC). This study included 80 subjects, comprising of 35 patients in each group of vasovagal syncope and postural tachycardia syndrome and 10 healthy subjects. Patients with complaint of syncope was evaluated for vasovagal syncope and postural tachycardia syndrome using Head Up Tilt Test (HUTT). Blood samples of all the participants were taken and serum cortisol was analyzed using ELISA method. Results were analyzed on SPSS Statistics 21 using ANOVA with a p-value of ≤0.05 regarded as significant. Results: Hormonal analysis shows that cortisol levels in the vasovagal, postural tachycardia syndrome and in control group was 153±16.7pg/ml, 160.17±pg/ml, and 69.65±5.8pg/ml respectively. Cortisol levels were significantly higher in both vasovagal and POTS groups as compared to controls with a p-value of 0.04 and 0.023 respectively. However, there was no significant difference between vasovagal and POTS patients with p value 0.570. Conclusion: It is concluded from the study that cortisol responses of VVS and POTS were positive. doi: https://doi.org/10.12669/pjms.38.1.4122 How to cite this:Khan HF, Ambreen S, Raziq H, Hayat A. Comparison of cortisol levels in patients with vasovagal syncope and postural tachycardia syndrome. Pak J Med Sci. 2022;38(1):---------. doi: https://doi.org/10.12669/pjms.38.1.4122 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

scholarly journals Robotic trans‐mitral septal myectomy and papillary muscle reorientation for HOCM combined with or without mitral valve repair: Technical aspects – How we do it

2020 ◽  
Vol 35 (11) ◽  
pp. 3120-3124
Author(s):  
Ashok Kumar C J ◽  
A. Marc Gillinov ◽  
Nicholas G. Smedira ◽  
Kevin Hodges ◽  
Daniel J. P. Burns ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Valve Repair ◽  
Papillary Muscle ◽  
Valve Repair ◽  
Technical Aspects ◽  
Septal Myectomy

scholarly journals P1273 Effects of surgical septal myectomy on left ventricular function in patients with hypertrophic obstructive cardiomyopathy

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
A Furugen ◽  
H D Doi ◽  
M H Hashimoto ◽  
R K Koshima ◽  
K M Mitsube
Keyword(s):  
Mitral Valve ◽  
Diastolic Function ◽  
Longitudinal Strain ◽  
Function Analysis ◽  
Left Ventricular ◽  
Volume Index ◽  
Lv Function ◽  
Septal Myectomy ◽  
Concomitant Procedure ◽  
Lv Diastolic Function

Abstract Introduction and Purpose Surgical left ventricular (LV) septal myectomy in patients with obstructive hypertrophic cardiomyopathyhas been shown to reduce left ventricular outflow tract (LVOT) gradient and improve symptoms. We investigated changes in strain analysis, LA volume and LV systolic and diastolic function in patients with HOCM after surgical septal myectomy. Methods We enrolled consecutive 30 patients (age 63.7 ± 11.0 years, 47% Female), who underwent surgical LV septal myectomy for HOCM from 2012 to 2019. We evaluated LV dimension, LVOTG, LV-stroke volume, LV in flow pattern (E wave, A wave, Dct), e’(septal and lateral), LA volume, mitral regurgitation (MR), systolic anterior motion of mitral valve (SAM) and Global longitudinal strain. These parameters were evaluated at baseline and after LV myectomy at medium term (at least 6 months after surgery). Results They are followed for a mean of 3.4± 1.9 years after surgery. Eight patients underwent concomitant procedure; mitral valve repair and annuloplasty in 3 patients (10%), Maze surgery in 1 patient, LV aneurysmectomy in 2 patients and aortic valve replacement in 3 patients (10%). Patients with concomitant procedure were excluded from LV function analysis. Postoperative LVOTG were controlled in 10mmHg or less.Global longitudinal strain (GLS) improved but no significant change. Otherwise LA volume index decreased (from 52.5 ± 16.7 to 32.9 ± 14.6 ml/m2, p = 0.01) and LV diastolic function improved with an increase in lateral e" velocity (from 4.5 ± 2.8 to 9.2 ± 3.4 cm/sec, p = 0.001) and improved E/e’ (from 18.9 ± 5.6 to 10.6 ± 5.2, p <0.05). Symptoms of dyspnea, chest oppression and heart failure improved with reduction in the New York Heart Association functional class. Conclusion Excellent relief of LVOT obstruction in HOCM by surgical LV septal myectomy results in decreased LA volume and LV diastolic function with improved symptoms.

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