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ACUTE ECHO-GUIDED MANAGEMENT OF CARDIOGENIC SHOCK AFTER ANTERIOR MYOCARDIAL INFARCTION COMPLICATED BY DYNAMIC LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION
2158 JACC March 21, 2017 Volume 69, Issue 11
FIT Clinical Decision Making ACUTE ECHO-GUIDED MANAGEMENT OF CARDIOGENIC SHOCK AFTER ANTERIOR MYOCARDIAL INFARCTION COMPLICATED BY DYNAMIC LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION Poster Contributions Poster Hall, Hall C Friday, March 17, 2017, 10:00 a.m.-10:45 a.m. Session Title: FIT Clinical Decision‐Making: Non-Invasive Imaging and Valvular Heart Disease Abstract Category: Non Invasive Imaging Presentation Number: 1129-382 Authors: Manan Shah, Jennifer Chao, Matthew Tomey, Stephen McCullough, Martin Goldman, Icahn School of Medicine, Mount Sinai Hospital, New York, NY, USA Background: Dynamic left ventricular outflow tract obstruction (LVOT) is a rare complication of acute myocardial infarction (MI). Early recognition is essential to guide treatment.
Case: A 55-year-old male presented with chest pain for 48 hours, and an ECG revealed ST elevations in V1-V6. Coronary angiography revealed a thrombotic occlusion of the mid-left anterior descending artery, and he underwent drug-eluting stent implantation. Post procedure, transthoracic echo showed mild left ventricular systolic dysfunction, and he was given lisinopril 2.5mg orally and furosemide 20mg orally. Over the next several hours, his heart rate increased to 120 bpm, BP decreased to 80/40 mmHg, and he had minimal urine output. He had a new systolic ejection murmur, new JVD, and newly cool extremities.
Decision‐Making: We performed a bedside echo which showed anterior and apical dyskinesis with basal hypercontractility, systolic anterior motion of the anterior mitral leaflet, moderate mitral regurgitation, and severe LVOT obstruction (gradient 66mmHg). We avoided inotropes, and treated with intravenous fluids, esmolol and phenylephrine titrated with serial bedside echocardiography. Over the subsequent hours, tachycardia resolved, and blood pressure normalized, and his serum creatinine returned to baseline. At 4-month follow up, echo showed apical dyskinesis with otherwise preserved systolic function and no evidence of LVOT obstruction.
Conclusions: Dynamic LVOT obstruction can be seen after anterior MI due to apical dyskinesis and compensatory basal hypercontractility. Early recognition with bedside echo is important as the management differs from the usual treatment for cardiogenic shock. Drugs that lower peripheral vascular resistance (nitrates and ACE inhibitors), and inotropes may exacerbate the dynamic obstruction, and should be avoided. Therapeutic measures include agents that reduce left ventricular contractility (beta-blockers, nondihydropyridine calcium channel blockers, and disopyramide) or increase peripheral vascular resistance (phenylephrine).
FIT Clinical Decision Making ACUTE ECHO-GUIDED MANAGEMENT OF CARDIOGENIC SHOCK AFTER ANTERIOR MYOCARDIAL INFARCTION COMPLICATED BY DYNAMIC LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION Poster Contributions Poster Hall, Hall C Friday, March 17, 2017, 10:00 a.m.-10:45 a.m. Session Title: FIT Clinical Decision‐Making: Non-Invasive Imaging and Valvular Heart Disease Abstract Category: Non Invasive Imaging Presentation Number: 1129-382 Authors: Manan Shah, Jennifer Chao, Matthew Tomey, Stephen McCullough, Martin Goldman, Icahn School of Medicine, Mount Sinai Hospital, New York, NY, USA Background: Dynamic left ventricular outflow tract obstruction (LVOT) is a rare complication of acute myocardial infarction (MI). Early recognition is essential to guide treatment.
Case: A 55-year-old male presented with chest pain for 48 hours, and an ECG revealed ST elevations in V1-V6. Coronary angiography revealed a thrombotic occlusion of the mid-left anterior descending artery, and he underwent drug-eluting stent implantation. Post procedure, transthoracic echo showed mild left ventricular systolic dysfunction, and he was given lisinopril 2.5mg orally and furosemide 20mg orally. Over the next several hours, his heart rate increased to 120 bpm, BP decreased to 80/40 mmHg, and he had minimal urine output. He had a new systolic ejection murmur, new JVD, and newly cool extremities.
Decision‐Making: We performed a bedside echo which showed anterior and apical dyskinesis with basal hypercontractility, systolic anterior motion of the anterior mitral leaflet, moderate mitral regurgitation, and severe LVOT obstruction (gradient 66mmHg). We avoided inotropes, and treated with intravenous fluids, esmolol and phenylephrine titrated with serial bedside echocardiography. Over the subsequent hours, tachycardia resolved, and blood pressure normalized, and his serum creatinine returned to baseline. At 4-month follow up, echo showed apical dyskinesis with otherwise preserved systolic function and no evidence of LVOT obstruction.
Conclusions: Dynamic LVOT obstruction can be seen after anterior MI due to apical dyskinesis and compensatory basal hypercontractility. Early recognition with bedside echo is important as the management differs from the usual treatment for cardiogenic shock. Drugs that lower peripheral vascular resistance (nitrates and ACE inhibitors), and inotropes may exacerbate the dynamic obstruction, and should be avoided. Therapeutic measures include agents that reduce left ventricular contractility (beta-blockers, nondihydropyridine calcium channel blockers, and disopyramide) or increase peripheral vascular resistance (phenylephrine).