Abstract 15934: Refractory Cardiogenic Shock in a Patient With Hypertrophic Obstructive Cardiomyopathy and Mitral Regurgitation Necessitating Intra-Aortic Balloon Pump Use

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Indrajeet Mahata ◽  
Michael Faulx ◽  
Snigdha kola ◽  
Sweta Singh
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Cardiogenic Shock ◽  
Pulmonary Edema ◽  
Muscle Protein ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Afterload Reduction ◽  
Intra Aortic Balloon Pump ◽  
Refractory Cardiogenic Shock

Introduction: Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disease due to a mutation in cardiac muscle protein resulting in left ventricular wall and septal hypertrophy. The presence of systolic anterior motion (SAM) of the mitral valve leads to dynamic left ventricular outflow tract (LVOT) obstruction. With increasing SAM of the anterior mitral leaflet there is resultant loss of coaptation leading to mitral regurgitation (MR). MR has been associated with HOCM but severe MR physiology causing refractory cardiogenic shock and requiring the use of afterload reduction through intra-aortic balloon pump (IABP) is rare and seems paradoxical to the conventional therapy for HOCM. Case summary: This is a case of 71year old female with HOCM, presenting with worsening shortness of breath. She had pulmonary vascular congestion on Chest X-ray and her Transthoracic Echocardiography demonstrated significant LVOT obstruction with moderate MR. She was being evaluated for myomectomy while being treated medically with beta blocker therapy for HOCM. She decompensated with acute respiratory failure from pulmonary edema, her blood pressure and oxygen saturation dropped. She was intubated. Swan- ganz catheter reading suggested wedge pressures of 22 and elevated pulmonary pressures. MvO2 was 32% and this was suggestive of cardiogenic shock. The Trans-esophageal echocardiogram (TEE) showed normal EF with severe concentric LVH and a moderate to severe (3+) MR due to restricted leaflet motion with regurgitant orifice area being 2.5cm2. At that point her MR was the dominant physiology behind her acute decompensation and cardiogenic shock and hence an IABP was placed for reducing afterload that helped in stabilizing her. Subsequently her wedge pressure and MvO2 improved, she was weaned off the IABP and extubated. The patient is being evaluated for myomectomy and mitral valve repair. Conclusion: This case illustrates complex hemodynamics and a challenging management due to competing MR and HOCM physiologies, too much central volume to offset HOCM may worsen MR and pulmonary edema while too much afterload reduction might worsen the HOCM. The use of IABP in a HOCM patient though seems paradoxical but was necessary in this setting to deal with complex physiologies.

Prophylactic LVAD Enabling High-Risk Mitral Repair—Extending Beyond the Guidelines

2019 ◽  
Vol 14 (6) ◽  
pp. 573-576
Author(s):  
Fadi Hage ◽  
Ali Hage ◽  
Stuart Smith ◽  
A. Dave Nagpal ◽  
Michael W. A. Chu
Keyword(s):  
High Risk ◽  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Cardiogenic Shock ◽  
Clinical Symptoms ◽  
Left Ventricular ◽  
Lv Function ◽  
Assist Device ◽  
Mitral Repair ◽  
Lv Dysfunction

Both surgical and percutaneous mitral repair remain contraindicated in patients with severe degenerative mitral regurgitation (DMR) with severe left ventricular (LV) dysfunction because of inadequate LV reserve and increased LV work with a competent mitral valve. We report a 55-year-old gentleman who presented in cardiogenic shock with missed severe DMR and severe LV dysfunction, in whom we performed a high-risk mitral repair and insertion of a prophylactic CentriMag LV assist device. This innovative approach was found to be successful with significant patient improvement in both LV function and clinical symptoms with a competent mitral valve.

scholarly journals Surgical Treatment for Hypertrophic Obstructive Cardiomyopathy with Concomitant Mitral Valve Abnormalities: A Cohort of 26 Cases

2018 ◽  
Vol 21 (6) ◽  
pp. E443-E447
Author(s):  
Bang-rong Song ◽  
Yanlong Ren ◽  
Hong-jia Zhang
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Left Ventricular Outflow Tract ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Outflow Tract ◽  
Systolic Anterior Motion ◽  
Left Ventricular Outflow ◽  
Mitral Apparatus

Background: We sought to analyze the pathological characteristics of hypertrophic obstructive cardiomyopathy (HOCM) with concomitant mitral valve abnormalities and to discuss the surgical treatment strategies. Methods: The clinical data of 26 HOCM patients treated from January 2014 to March 2016 were retrospectively analyzed. There were 19 males and 7 females with a mean age of 47 ± 16 years (range, 10-70 years). Echocardiography showed HOCM, systolic anterior motion of the mitral apparatus, and concomitant mitral regurgitation. Modified Morrow procedure with expanded resection area was performed in 21 patients. Concomitant mitral valvuloplasty was performed in 4 patients, coronary artery bypass grafting was performed in one patient, and aortic valve replacement was performed in one patient. Echocardiography was performed intraoperatively at postoperative 1 week and at postoperative 1 year to evaluate the left ventricular obstruction and the mitral regurgitation. Results: The left ventricular outflow tract gradient, left ventricular outflow tract velocity, septal thickness, and mitral regurgitation area decreased significantly at postoperative 1 week and 1 year in comparison with the baseline (all P < .001). The postoperative mitral regurgitation and systolic anterior motion of the mitral apparatus were completely abolished or significantly relieved. Only one patient had moderate mitral regurgitation of 7 cm2 after the surgery. At postoperative 1 year, all patients were asymptomatic, and the quality of life was significantly improved. The New York Heart Association (NYHA) class was I-II. Echocardiography showed good anatomy and function of the mitral valve. Conclusions: Concomitant mitral valve abnormality is not uncommon in HOCM. Septal myectomy can adequately expand the left ventricular outflow tract and abolish mitral regurgitation and systolic anterior motion of the mitral apparatus. Concomitant mitral valvuloplasty is indicated for severe congenital abnormalities or secondary lesions of the mitral valve, and the outcomes are satisfactory.

scholarly journals Efficacy of left atrial plication for atrial functional mitral regurgitation

2020 ◽  
Author(s):  
Masamichi Matsumori ◽  
Motoharu Kawashima ◽  
Takamitsu Aihara ◽  
Jun Fujisue ◽  
Masato Fujimoto ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Left Atrial ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Functional Mitral Regurgitation ◽  
Ventricular Ejection Fraction ◽  
Structural Valve Deterioration

Abstract Objective Atrial functional mitral regurgitation (AFMR) is caused by atrial fibrillation and left atrial enlargement. Our study aimed to evaluate the efficacy of left atrial plication (LAP) for AFMR. Methods Of 1164 mitral valve surgery patients at our hospital from January 2000 to May 2019, 22 patients underwent surgery for AFMR. Our retrospective analysis divided the patients with AFMR into two groups according to whether LAP was performed (LAP + group, n = 9; LAP − group, n = 13). Mitral valve angle (MV angle) (horizontal inclination of mitral valve) was measured by pre- and post-operative computed tomography scan. Individuals with type II mitral regurgitation, left ventricular ejection fraction of < 55%, males with left ventricular endo-diastolic dimension of > 60 mm and females with > 55 mm, aortic valve disease, mitral valve calcification, hypertrophic obstructive cardiomyopathy, and both “redo” and emergency cases were excluded. Result Mitral valve replacement was performed in 6 patients and mitral ring annuloplasty in 16 cases. No recurrence of mitral regurgitation or structural valve deterioration occurred during the follow-up period. There were no hospital deaths; 3 deaths occurred during the follow-up period. Compared to the LAP − group, the LAP + group demonstrated a significantly greater decrease of MV angle (16.6 ± 8.1° vs. 1.2 ± 6.9°, p < 0.01) and left atrial dimension (18.4 ± 7.0 mm vs. 6.9 ± 14.6 mm, p = 0.02). Conclusions Surgical results of AFMR were satisfactory. LAP may be appropriate for correcting the angle of a mitral valve tilted horizontally. More cases need to be considered in the future.

P893Alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy: experience at a reference center in Chile

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
F Verdugo ◽  
P Cataldo ◽  
C Dauvergne ◽  
J Sandoval
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Average Length ◽  
Beta Blockers ◽  
Nyha Class ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Alcohol Injection ◽  
Septal Thickness

Abstract Background Depending on the severity of septal hypertrophy and mitral valve derangements, patients with hypertrophic cardiomyopathy may develop left ventricular outflow tract (LVOT) obstruction and mitral regurgitation, which have major impact on symptoms and prognosis.Surgical myomectomy has been considered standard treatment in patients with hypertrophic obstructive cardiomyopathy (HOCM) who remain symptomatic despite medical therapy.Alcohol septal ablation (ASA), is a minimally invasive therapy for HOCM. Purpose Our aim was to assess short and long term outcomes and complications of ASA performed to symptomatic HOCM patients in our center. Methods We performed a retrospective observational study of patients undergoing ASA for HOCM between January 2002 and September 2018. According to local protocol, clinical evaluation and echocardiography were performed at baseline and 6 months after ASA. Local databases were reviewed, along with direct patient contact when required. Results ASA was performed in 73 patients with HOCM.Mean age was 57.5±12.8 years; 63% were male; 83.5% were on III-IV NYHA class, 32.9% had syncope; 12.3% had family history of sudden cardiac death, 93.6% received beta blockers, 6.8% had implantable cardioverter defibrillator.Mean alcohol injection per procedure was 2.45±1.03 cc. Invasive resting gradients were acutely reduced from 61.2±36.3 mmHg to 23.4±27.5 mmHg (p<0.001), and dynamic gradients from 106.5±37.3 mmHg to 31.0±28.0 mmHg (p<0.001). Hemodynamic success (reduction in resting gradient to <30 mmHg or dynamic gradient >50%) was achieved in 82.2% patients. We observed improvements in mitral regurgitation at ventriculography (Figure 1A, p<0.001), a decline of ≥1 severity degree was noticed in 53 patients (72.6%). Maximal creatine kinase after ASA was 2055±851 U/l. Average length of hospitalization was 4.4±5.0 days. Reablation was performed in 12 patients, 7 were planned staged procedures and 5 due to unsuccessful ASA. We observed no in-hospital mortality. Permanent pacemaker were implanted in 9 patients. Vascular access complications occurred in 3 patients. Coronary dissection and cardiac tamponade occurred in 1 patient respectively. Complications were more frequent after reablation (50% vs 17%, p<0.01).At 6 months, we observed improvements in NYHA class (Figure 1B, p<0.001), a decline of ≥1 NYHA class was found in 68 patients (93.2%). Echocardiographic assessment exposed reductions in septal thickness (25.0±5.5 vs 17.1±5.3 mm, p<0.001), LVOT gradients (86.7±27.3 vs 38.4±15.1 mmHg, p<0.001) and systolic anterior motion of the mitral valve prevalence (61.6% vs 27.4%, p=0.002). At 12 months, we detected only 1 death due to COPD.No cardiovascular deaths were noted in patients achieving 5 years of follow-up (n=49). Figure 1 Conclusion ASA was a safe and effective procedure in symptomatic HOCM, resulting in reductions of septal thickness, LVOT gradients and mitral regurgitation severity, as well as an improvement in NYHA class.

scholarly journals P1698 Mitral valve endocarditis in hypertrophic obstructive cardiomyopathy

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
E Shirka ◽  
H Gjergo ◽  
O Avdullari ◽  
A Goda
Keyword(s):  
Heart Disease ◽  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Outflow Tract ◽  
Valve Leaflet ◽  
Systolic Anterior Motion ◽  
Mitral Valve Leaflet ◽  
History Of

Abstract Introduction Endocarditis complicating hypertrophic cardiomyopathy (HCM) is not commonly reported but occurs almost universally in patients showing evidence of outflow tract obstruction. The estimated cumulative 10 year probability of developing endocarditis in obstructive HCM is &lt; 5%. We report a rare case of mitral valve endocarditis in a young man with hypertrophic obstructive cardiomyopathy. Case report A 45 years old man was admitted to the emergency room after a 7 days history of weakness, thoracic discomfort, short of breath, cough and temperature up to 40 °C. He was treated with oral antibiotics in ambulatory setting, but symptoms persisted. He had no previous history of hypertension or known heart disease, family history of coronary heart disease and excessive smoker. On clinical examination, the patient was afebrile with a harsh systolic murmur. Initial blood tests showed normal inflammatory markers (C reactive protein 0.2 mg/l and fibrinogen 202 mg/dL) and normal blood sample. An ECG showed major left ventricular hypertrophy and abnormal lateral repolarisation. Transthoracic echocardiography showed localized septal hypertrophy (2.4 cm) and systolic anterior motion of the anterior mitral leaflet. Continuous wave Doppler ultrasound in the left ventricular cavity and outflow tract, had given a maximal predicted gradient of 73 mmHg. There was suspicion of vegetation on the anterior mitral valve leaflet and mitral regurgitation was quantified as moderate. Transoesophageal echocardiography confirmed the presence of vegetation on the anterior mitral valve leaflet, posterior leaflet prolapse and moderate mitral regurgitation. We found normal coronary arteries on coronary angio-CT. Treatment with intravenous antibiotics was initiated and the case was discussed with a microbiologist and a cardiothoracic surgeon. Discussion Infective endocarditis is a rare complication of hypertrophic cardiomyopathy (HCM). It is clear from morphological studies that systolic anterior motion of the anterior mitral valve leaflet is relevant to the pathogenesis of endocarditis. Pathogenesis of infective endocarditis in obstructive HCM can be explained by endocardium damage of the mitral or aortic valve, consequence of turbulence of blood flow during ejection and of the contact between the mitral anterior leaflet and the septum during systole as well as mitral regurgitation. Antibiotic therapy is the mainstay of the treatment. Surgery should be considered promptly whenever there is traditional indication (haemodynamic, emboli, persistent fever, abscess). Surgical procedure may consist of valve replacement or repair, and some authors reported relieve of outflow tract obstruction after mitral valve replacement which may be explained by the removal of systolic anterior motion of the mitral valve. Valve surgery combined with septal myectomy seems logical but requires great expertise and carries a higher operative mortality Abstract P1698 Figure.

Extended Myectomy for Hypertrophic Obstructive Cardiomyopathy

2012 ◽  
Vol 15 (5) ◽  
pp. 251
Author(s):  
Changqing Gao ◽  
Chonglei Ren ◽  
Cangsong Xiao ◽  
Yang Wu ◽  
Gang Wang ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Left Ventricle ◽  
Mitral Regurgitation ◽  
Surgical Procedures ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Systolic Anterior Motion ◽  
Anterior Leaflet ◽  
Septal Myectomy ◽  
The Mean

<p><b>Background:</b> The purpose of this study was to summarize our experience of extended ventricular septal myectomy in patients with hypertrophic obstructive cardiomyopathy (HOCM).</p><p><b>Methods:</b> Thirty-eight patients (26 men, 12 women) with HOCM underwent extended ventricular septal myectomy. The mean age was 36.3 years (range, 18-64 years). Diagnosis was made by echocardiography. The mean (mean � SE) systolic gradient between the left ventricle (LV) and the aorta was 89.3 � 31.1 mm Hg (range, 50-184 mm Hg) according to echocardiographic assessments before the operations. Moderate or severe systolic anterior motion (SAM) of the anterior leaflet of the mitral valve was found in 38 cases, and mitral regurgitation was present in 29 cases. Extended ventricular septal myectomy was performed in all 38 cases. The results of the surgical procedures were evaluated intraoperatively with transesophageal echocardiography (TEE) and with transthoracic echocardiography (TTE) at 1 to 2 weeks after the operation. All patients were followed up with TTE after their operation.</p><p><b>Results:</b> All patients were discharged without complications. The TEE evaluations showed that the mean systolic gradient between the LV and the aorta decreased from 94.8 � 35.6 mm Hg preoperatively to 13.6 � 10.8 mm Hg postoperatively (<i>P</i> = .0000) and that the mean thickness of the ventricular septum decreased from 28.3 � 7.9 mm to 11.8 � 3.2 mm (<i>P</i> = .0000). Mitral regurgitation and SAM were significantly reduced or eliminated. During the follow-up, all patients promptly became completely asymptomatic or complained of mild effort dyspnea only, and syncope was abolished. TTE examinations showed that the postoperative pressure gradient either remained the same or diminished.</p><p><b>Conclusions:</b> Extended ventricular septal myectomy is mostly an effective method for patients with HOCM, and good surgical exposure and thorough excision of the hypertrophic septum are of paramount importance for a successful surgery.</p>

scholarly journals Ventricular arrhythmias in patients with functional mitral regurgitation and implantable cardiac devices: implications of mitral valve repair with Mitraclip

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
T Benito Gonzalez ◽  
X Freixa ◽  
C Godino ◽  
M Taramasso ◽  
R Estevez-Loureiro ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Mitral Valve Repair ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Functional Mitral Regurgitation ◽  
Valve Repair ◽  
One Year ◽  
The Impact

Abstract Background Limited information has been reported regarding the impact of percutaneous mitral valve repair (PMVR) on ventricular arrhythmic (VA) burden. The aim of this study was to address the incidence of VA and appropriate antitachycardia implantable cardiac defibrillator (ICD) therapies before and after PMVR. Methods We retrospectively analyzed all consecutive patients with heart failure with reduce left ventricular ejection fraction, functional mitral regurgitation grade 3+ or 4+ and an active ICD or cardiac resynchronizer who underwent PMVR in any of the eleven recruiting centers. Only patients with complete available device VA monitoring from one-year before to one year after PMVR were included. Baseline clinical and echocardiographic characteristics were collected before PMVR and at 12-months follow-up. Results 93 patients (68.2±10.9 years old, male 88.2%) were enrolled. PMVR was successfully performed in all patients and device success at discharge was 91.4%. At 12-months follow-up, we observed a significant reduction in mitral regurgitation severity, NT-proBNP and prevalence of severe pulmonary hypertension and severe kidney disease. Patients also referred a significant improvement in NYHA functional class and showed a non-significant trend to reserve left ventricular remodeling. After PMVR a significant decrease in the incidence of non-sustained ventricular tachycardia (VT) (5.0–17.8 vs 2.7–13.5, p=0.002), sustained VT or ventricular fibrillation (0.9–2.5 vs 0.5–2.9, p=0.012) and ICD antitachycardia therapies (2.5–12.0 vs 0.9–5.0, p=0.033) were observed. Conclusion PMVR was related to a reduction in arrhythmic burden and ICD therapies in our cohort. Proportion of patients who presented ven Funding Acknowledgement Type of funding source: None

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