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PubMed1996

Atypical electromechanical dissociation in a patient with recurrent pulmonary embolism.

A 47-year-old man experienced recurrent pulmonary embolism resistant to aggressive medical and surgical prophylaxis. Although paraneoplastic hypercoagulability was suspected, no endoscopic or radiologic signs of malignancy were detected. Death was the result of electromechanical dissociation, which was attributed to right ventricular outflow obstruction. At autopsy, anaplastic lung carcinoma was found in the left basal segment with superimposed pulmonary infarction. A huge pedunculated thrombus was attached to the left ventricular apex and extended into the ascending aorta, obstructing the left ventricular outflow. To our knowledge, this is the first case of electromechanical dissociation due to left ventricular thrombus in a patient with pulmonary embolism. Radiologic and echocardiographic evaluation of such patients should take into account possible masking of the underlying neoplasm by embolic or hemorrhagic phenomena, or both, and the presence of left-sided cardiac thombi, which may cause catastrophic events.

Arrhythmias, Cardiac↗
PubMed1996

[A case report of an infundibular ventricular septal defect with severe right ventricular outflow tract obstruction due to aneurysm of the aortic sinus of valsalva].

This paper describes the case of a 46-year-old female. Upon contacting infective endocarditis at the age of 39 years, she was diagnosed with a ventricular septal defect (VSD). Because dyspnea gradually worsened, she was later hospitalized. Cardiac catheterization was performed and angiograms were taken, revealing an infundibular VSD accompanied by severe right ventricular outflow tract obstruction (RVOTO) due to aneurysm of aortic sinus of valsalva and to mild aortic regurgitation caused by prolapsing aortic valve. The operative procedure consisted of the closure of the aortic sinus fistula by continuous suture after excision of the aneurysmal sac and patch closure of the VSD without treatment of the prolapsing aortic valve. After the operation, RVOTO improved and aortic regurgitation disappeared. The patient was discharged and has since been well.

Aortic Aneurysm↗
PubMed1979

[Transposition of the great arteries: anatomic types of left ventricular outflow tract obstruction (author's transl)].

A postmortem investigation has been carried out in 48 heart specimens with transposition of the great arteries (TGA) to evaluate incidence and type of left ventricular outflow tract obstruction. The frequence of pulmonary stenosis in our series (23%) is similar to those reported from previous studies. Cases have been divided in two groups according to presence or absence of ventricular septal defect. In cases with intact ventricular septum the obstruction was determined by asymmetric hypertrophy of the septum (1 observation) and by abnormal attachement of clefted anterior mitral leaflet to the interventricular septum (2 observations). In the specimens with ventricular septal defect, 4 presented a stenosis due to malalignment of the infundibular septum, associated with valvular stenosis in 1 case and with valvular stenosis and fibrous subvalvular ring in 2. Another case presented a stenotic pulmonary valve and a parachute mitral valve. The remaining 3 showed a cleft of the anterior leaflet of the mitral valve. The high incidence of infundibular malalignment obstruction is underlined together with its association with A-P or L-position of the aorta. This peculiar relation of the great arteries could be angiocardiographically employed as indicative for the presence of this type of left outflow tract obstruction in TGA.

Female↗
PubMedDate not supplied

Utility of intraoperative transesophageal echocardiography in the assessment of residual cardiac defects.

To investigate the accuracy of immediate postbypass transesophageal echocardiography in the assessment of residual cardiac defects, we compared intraoperative transesophageal echocardiograms with intra/postoperative data in 86 patients, aged 4 days to 30.7 years (median = 1.4 years), at risk for a total of 174 postoperative lesions: right (n = 55) or left (n = 26) ventricular outflow tract obstruction, ventricular septal defect (n = 65), aortic (n = 12) or mitral regurgitation (n = 8), or mitral stenosis (n = 8). Accuracy of intraoperative transesophageal echocardiography was evaluated based on comparison with (1) immediate post-bypass left (n = 4) or right (n = 9) ventricular outflow tract pressure gradients by pullback in the operating room, (2) direct surgical inspection of residual ventricular septal defects (n = 3), (3) pulmonary artery oxygen saturation (n = 49), (4) right ventricular outflow tract pullback gradient (n = 24), and (5) transthoracic echocardiogram (n = 51) performed within 40 days of surgery. The results indicate that intraoperative transesophageal echocardiography agreed with intra/postoperative data in 87% of patients at risk for right ventricular outflow tract obstruction, 96% at risk for left ventricular outflow tract obstruction, 97% at risk for ventricular septal defect, and 100% at risk for aortic regurgitation, mitral regurgitation, or mitral stenosis. Significant residual lesions led to immediate surgical revision in 11 cases: 3 ventricular septal defects, 6 right and 2 left ventricular outflow tract obstructions. Of these, intraoperative transesophageal echocardiography confirmed and quantified suspected residual lesions in 7 and identified unsuspected lesions in 4 cases. Immediate postbypass transesophageal echocardiography proved reliable for assessing residual ventricular septal defect, mitral stenosis, and mitral or aortic regurgitation. Although accurate for assessment of the left and right ventricular outflow tracts in most patients, transesophageal echocardiography may not reliably reflect the severity of obstruction in all cases.

Adolescent↗
PubMed1987

Assessment of residual right ventricular outflow tract obstruction following surgery using the response to intravenous propranolol.

The response to intravenous administration of propranolol hydrochloride was studied in 24 children undergoing operation for isolated or complex right ventricular outflow tract obstruction. Ten had pulmonary valve stenosis, 4 had pulmonary valve stenosis plus ventricular septal defect, 8 had tetralogy of Fallot, and 2 had complex lesions. Propranolol (0.01 to 0.2 mg per kilogram of body weight) was given to patients with a residual right ventricular to left ventricular systolic pressure ratio greater than 0.75. Four children did not respond to propranolol and required further surgical intervention. Twenty patients responded, 2 of whom died. Fifteen were restudied by cardiac catheterization 3 weeks to 27 months postoperatively. The right ventricle-pulmonary artery gradient was 25 mm Hg or less in 13 patients. We conclude that a small dose of propranolol given intraoperatively can identify patients in whom a reduction in the right ventricle-pulmonary artery gradient to acceptable levels will occur in the months following operation. This may reduce the need for placement of a subannular or transannular patch in some patients.

Blood Pressure↗
PubMed2000

Transformation of mitral valve prolapse to dynamic left ventricular outflow tract obstruction and back again in a patient with acute transient myocardial depression.

We describe an unusual case of transient resolution of preexisting mitral valve (MV) prolapse during acute cardiac dysfunction and the development of dynamic left ventricular (LV) outflow tract obstruction. The patient presented with lightheadedness, chest pain, and compromised hemodynamic status. Echocardiography revealed akinesis and deformation of the LV anterior wall and apex, hyperdynamic activity in the bases, anterior MV leaflet systolic anterior motion without prolapse, and a dynamic outflow tract gradient. Myocardial function fully recovered over 1 month. Repeat ultrasonography showed posterior MV leaflet prolapse and no anterior MV leaflet systolic anterior motion. Elongated MV leaflets may have contributed to dynamic outflow tract obstruction and life-threatening hemodynamic compromise during LV conformational change.

Female↗
PubMed1999

[Transitory left ventricular outflow tract obstruction after mitral valve reconstruction].

HISTORY AND ADMISSION FINDINGS: A few days after uneventful surgical reconstruction of the mitral valve a 43-year-old man was found to have a systolic murmur due to prolapse of the posterior leaflet, suggesting renewed mitral regurgitation. INVESTIGATIONS: Echocardiography revealed haemodynamically significant left ventricular outflow tract obstruction (LVOT) with a left ventricle to aorta systolic gradient of 83 mm Hg. In addition there was moderately severe mitral regurgitation as well as a pericardial effusion but no signs of tamponade. TREATMENT AND COURSE: The obstruction was at first treated with verapamil, later with sotalol. The pericardial effusion was interpreted as part of a postcardiotomy syndrome. The effusion regressed under steroid administration, and the LVOT and mitral regurgitation also decreased. A provocation test five months postoperatively no longer brought about an outflow gradient. The good results were still present 12 months postoperatively. CONCLUSION: The described, rarely seen form of LVOT was probably caused by a combination of a very large anterior mitral leaflet, postoperative pericardial effusion and pharmacological effects. If the obstruction first occurs postoperatively, appropriate medication may improve the cardiac status and reoperation may be avoided. Echocardiography is an important method of diagnosis and serial monitoring.

Adrenergic beta-Antagonists↗
PubMed2003

[Left ventricular outflow tract obstruction in transposition of the great arteries. Correlation between anatomic and echocardiographic findings].

INTRODUCTION AND OBJECTIVES: Left ventricle outflow tract obstructions in transposition of the great arteries are frequent. We report the correlations between two-dimensional echocardiographic and autopsy findings to draw attention to the usefulness of this diagnostic method in the preoperative evaluation of these anomalies. MATERIAL AND METHODS: Of 73 hearts with transposition of great arteries, 26 specimens (38%) with different types of left ventricular outflow tract obstruction were selected to establish the relationship between an anatomical substrate of obstruction and echocardiographic findings in equivalent hearts. Pulsed-wave Doppler studies of velocities at the site of stenosis were done with high-pulse-rate frequency and continuous wave techniques. Eight echocardiographic studies of anatomical specimens and 10 studies in equivalent hearts used for comparison were analyzed to determine correlations. RESULTS: Twenty-eight obstructions were found; the most frequent type being left ventricular outflow tract alteration (77%). The most frequent anomalies were posterior deviation of the infundibular septum, cone-like obstruction, pulmonary valve stenosis and septal hypertrophy, followed by congenital mitral valve anomalies (15 %) and anomalies of the tricuspid valve (8%). Two-dimensional echocardiographic studies revealed different types anatomical obstruction. CONCLUSIONS: We found precise correlations between the anatomical obstruction and its echocardiographic image. Evaluating electrocardiographic findings is important because these findings can affect the choice of surgical treatment or even the decision to use surgery.

Humans↗
PubMed1996

[Dobutamine stress causes left ventricular outflow tract obstruction].

Hypotension during dobutamine stress echocardiography is caused by ischemia as well as non-ischemic causes. Whether sigmoid interventricular septum seen in the aged can cause hypotension during dobutamine stress echocardiography was investigated in eight men and four women with sigmoid interventricular septum (aged 53 to 76 years, mean 67 +/- 7 years). At peak dobutamine dose, seven patients (group H) showed a hypotensive response (defined as 5 mmHg or greater decrease in systolic blood pressure from the peak systolic blood pressure; mean = - 17 +/- 13 mmHg), while five subjects (group N) did not. No subject showed regional wall motion abnormalities. Before dobutamine infusion, group H had smaller left ventricular end-systolic dimension (26 +/- 3 vs 30 +/- 3 mm) than group N, but no difference was found in left ventricular end-diastolic dimension (44 +/- 3 vs 47 +/- 4 mm), percentage fractional shortening (40 +/- 6% vs 34 +/- 7%), diastolic aorto-septal angle (82 +/- 10 vs 95 +/- 11 degrees), systolic aorto-septal angle (94 +/- 10 vs 101 +/- 11 degrees), peak left ventricular outflow velocity (1.3 +/- 0.2 vs 1.2 +/- 0.3 m/sec) or peak left ventricular outflow pressure gradient (7 +/- 2 vs 6 +/- 3 mmHg). Group H had a lower peak dobutamine dose than group N (33 +/- 8 vs 40 +/- 7 micrograms/kg/min), but under the peak dose of dobutamine infusion group H showed smaller left ventricular end-systolic dimension (20 +/- 3 vs 26 +/- 4 mm), systolic mitral annulus diameter (19 +/- 3 vs 23 +/- 2 mm), diastolic aorto-septal angle (72 +/- 16 vs 92 +/- 6 degrees), and systolic aorto-septal angle (84 +/- 12 vs 100 +/- 6 degrees), and higher heart rate (114 +/- 10 vs 79 +/- 16 bpm), percentage fractional shortening (53 +/- 8% vs 43 +/- 7%), peak left ventricular outflow velocity (3.2 +/- 0.8 vs 1.7 +/- 0.3 m/sec), and peak left ventricular outflow pressure gradient (43 +/- 23 vs 12 +/- 5 mmHg). In addition, systolic anterior motion of the mitral valve with septal contact developed in 86% of group H and 0% of group N. Thus, about half of the patients with sigmoid interventricular septum show hyperresponse to dobutamine and develop dynamic left ventricular outflow tract obstruction as well as systemic arterial hypotension even without regional left ventricular wall motion abnormalities.

Aged↗
PubMed1983

Prediction of the severity of left ventricular outflow tract obstruction by quantitative two-dimensional echocardiographic Doppler studies.

In this study we explored the use of continuous wave Doppler echocardiography guided by simultaneous two-dimensional echocardiographic imaging as a method for noninvasively estimating pressure gradients in patients with discrete forms of left ventricular outflow tract obstruction. We studied 16 children, ages 6 months to 17 years, with valvular aortic stenosis (n = 12) or with discrete subaortic stenosis (n = 4) and compared maximal Doppler velocities in the aorta with pressure gradients obtained at cardiac catheterization. Examinations could be performed from the suprasternal notch view or from the apical left ventricular outflow tract view with equal accuracy for the study of flow in the left ventricular outflow tract, and results were comparable in both views. With a simplified Bernoulli relationship (gradient = 4 X [maximal velocity]2), results suggested that Doppler echocardiography could be used to predict the severity of obstruction in our patients with a correlation coefficient of r = .94 (SEE +/- 7.5 mm Hg) between Doppler-estimated gradients and gradients obtained at catheterization. The method appears promising for initial evaluation and for serial management of patients with discrete forms of left ventricular outflow tract obstruction.

Adolescent↗
PubMed2005

Left ventricular outflow tract obstruction provoked during dobutamine stress echocardiography predicts future chest pain, syncope, and near syncope.

BACKGROUND: Although dobutamine stress echocardiography (DSE) is associated with dynamic left ventricular (LV) obstruction, it is unknown whether such obstructive event, in general, and the specific site of obstruction, in particular, have unique clinical prognostic significance. We sought to determine whether dynamic LV outflow tract (LVOT) versus LV midcavitary obstruction provoked during DSE would predict future chest pain, syncope, and/or near syncope. METHODS: Two hundred thirty-seven patients (145 men and 92 women, mean age 58 +/- 13 [+/-SD] years) without DSE-provoked ischemia underwent continuous wave Doppler interrogation to detect any inducible dynamic flow obstruction. Patients were prospectively followed for a mean duration of 31 +/- 13 months. RESULTS: One hundred fifty-four of 237 patients had no provoked LV obstruction (group 1). Fifty-four (22.8%) had provoked LV midcavitary (group 2) obstruction, and 29 (12.2%) had outflow tract (group 3) obstruction. During follow-up, chest pain occurred more frequently in groups 2 (46%, P < .05) and 3 (52%, P = .05) as compared with group 1 (31%). A higher incidence of syncope and/or near syncope was noted in group 3 (21% vs 9% in group 1). LVOT obstruction but not midcavitary obstruction was a significant predictor of future chest pain (relative risk 2.63, P = .0021) and syncope and/or near syncope (relative risk 3.11, P = .036). Kaplan-Meier analysis showed a significantly less event-free survival (P = .025) for the combined end point of chest pain, syncope, and/or near syncope in patients with LVOT obstruction. CONCLUSIONS: This is the first prospective study to identify the differential prognostic implications of the site of dynamic obstruction noted during DSE. Our results demonstrate that DSE-provoked LVOT obstruction is an independent positive predictor of future episodes of chest pain and syncope and/or near syncope. These findings warrant larger studies addressing treatment options to ameliorate symptoms in this subgroup of patients.

Adult↗
PubMed2004

[Dynamic left ventricular outflow tract obstruction induced by exercise].

INTRODUCTION AND OBJECTIVES: Dynamic left intraventricular outflow tract obstruction occurs occasionally in patients without hypertrophic cardiomyopathy. We hypothesized that dynamic intraventricular obstruction might occur during effort in patients with angina or dyspnea without evident disease. The objective of this prospective study was to investigate: a) whether it appears with effort; b) its incidence, magnitude and determining factors, and c) its clinical course. PATIENTS AND METHOD: We performed baseline and stress Doppler echocardiography in 211 patients with angina, dyspnea or both with exercise. Patients with previous myocardial infarction, valvular heart disease, ventricular dysfunction or ventricular hypertrophy without hypertension were excluded. Dynamic intraventricular obstruction was defined as intracavitary flow velocity > or =2.5 m/s. RESULTS: 134 patients (59 women) were included: mean age was 58 (9) years; history of hypertension was present in 69.7%, dyslipidemia in 35.8% and diabetes in 24.6%. Dynamic intraventricular obstruction appeared in 18 patients (13.4%), with gradients ranging between 25 and 53 mmHg (mean 32.19 [6.6]). Demographic variables, cardiovascular risk factors and exercise performed were similar in group A (with obstruction) and group B (without obstruction). No patient in group A had evidence of ischemia. Five patients in this group had symptoms during exercise; the gradients were greater in these patients (42.65 [10.5] vs 28.15 [2.37] mmHg; P<.0001) than in the remaining group A patients. Left ventricular outflow tract size was found to be the only independent predictive factor in the multivariate analysis. After 369.9 (133.5) days of follow-up, no cardiac events were recorded. CONCLUSIONS: Our study suggests that some patients with angina or dyspnea without evidence of ischemia may develop dynamic left ventricular outflow tract obstruction induced by effort.

Adult↗
PubMed2000

Modified Rastelli using an autograft: A new concept for correction of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction (with an extension to other congenital heart defects).

We describe in this article a new approach in transposition of the great arteries (TGA), ventricular septal defect (VSD), and left ventricular outflow tract obstruction (LVOTO). It consists of an operation combining the intracardiac infundibular resection of the Lecompte procedure to allow a direct VSD-aorta connection and the right ventricle-pulmonary artery (RV-PA) connection with a segment of tubular aortic autograft, (with or without an additional monocusp patch). Thus, a viable conduit, capable of growth, is interposed between RV and PA. We have performed this procedure in 19 patients (age, 2 months to 11 years), 6 being under 1 year. All patients are doing well after a maximum follow-up of 72 months, exhibiting growth of the conduit and satisfactory RV pressures. This new approach allows primary correction even in the young and can be extended, we think, for other defects with pulmonary stenosis or atresia. It shares, however, with many other procedures, the valveless nature of the repair with the potential late need for valve replacement surgery. Copyright 2000 by W.B. Saunders Company

Journal Article↗
PubMed1991

Natural history of apical left ventricular to aortic conduits in pediatric patients.

To determine the long-term efficacy of apical left ventricular to aortic conduits in palliating complex left ventricular outflow obstruction, we reviewed our entire experience of 20 pediatric patients who underwent placement of a composite porcine valve-bearing conduit from the left ventricular apex to the aorta from November 1977 to April 1987. There were two early postoperative deaths, both in infants less than 2 months of age at the time of surgery. The remaining 18 patients had successful conduit placement with significant relief of the left ventricular outflow obstruction. Conduits have remained functional from 3 to greater than 9 years after initial placement. Long-term maintenance of a well-functioning conduit was limited by conduit heterograft valve dysfunction secondary to degeneration and calcification, with a 3-year conduit survival of 80 +/- 9% and a 7-year survival of 52 +/- 11%. Clinical identification of conduit valve insufficiency was found to be a useful early indicator of impending conduit failure, frequently preceding other signs and symptoms of conduit valve dysfunction. Eight patients required reoperation for conduit failure, and there were two late deaths associated with conduit valve dysfunction. Other long-term complications were rare. No thromboembolic events occurred despite avoidance of anticoagulant therapy, and there were no documented episodes of bacterial endocarditis. Thus, apical aortic conduit placement is an effective surgical technique for intermediate palliation of complex left ventricular outflow obstruction and may be useful in selected pediatric patients as a staging procedure before left ventricular outflow reconstruction.

Adult↗
PubMedDate not supplied

The inflexible mitral annulus after valve prosthesis. Inherent risk of dynamic left ventricular outflow tract obstruction.

Although chordal preserving mitral valve replacement is beneficial to cardiac function, the loss of flexibility of the annulus and consequent translational motion of the valve prosthesis during systole may cause potential left ventricular outflow tract (LVOT) obstruction after surgery. The extent of the flexibility of the mitral valve annulus (MVA) necessary for the prosthetic valve to prevent potential LVOT obstruction was determined. The three dimensional images of the MVA at 0, 100, 200, and 300 msec delay from the electrocardiogram R wave were reconstructed from cine-mode magnetic resonance images in eight normal subjects. In the lateral view of the MVA, the dorsal flexion angle (DFA) was defined. This angle implies the extent of the flexion of the anterior half of the MVA in relation to the posterior half. The data (mean +/- SD) for the DFA were 31.7 +/- 5.4 degrees (0 msec), 36.4 +/- 4.5 degrees (100 msec), 39.0 +/- 3.8 degrees (200 msec), and 43.6 +/- 2.6 degrees (300 msec), whereas the systolic increase in DFA was 11.9 +/- 3.2 degrees. The flexibility observed in normal mitral annuli is relevant to prosthetic mitral valves.

Adult↗