Key result
Accelerated junctional rhythm triggers dynamic LVOTO post-TAVI requiring targeted hemodynamic management.
Why the study?
Suicide left ventricle is a rare complication after TAVI, and the role of accelerated junctional rhythm in precipitating it had not been reported.
Accelerated junctional rhythm is a novel trigger for suicide left ventricle after TAVI, which can be effectively managed with volume loading, vasoconstrictors, and right ventricular pacing.
Alerts clinicians to monitor junctional rhythms post-TAVI; hypothesis-generating for suicide LV mechanisms and requires prospective validation.
Background Suicide left ventricle (LV) is a rare, potentially fatal complication after transcatheter aortic valve implantation (TAVI). It is typically caused by dynamic left ventricular outflow tract obstruction (LVOTO) following abrupt afterload reduction. Accelerated junctional rhythm (AJR) is an uncommon peri-procedural arrhythmia, and its role in precipitating suicide LV has not been reported. Case Summary An 87-year-old woman with extremely severe aortic stenosis was admitted for transfemoral TAVI. Concentric LV hypertrophy with a sigmoid septum and preserved systolic function was observed on baseline transthoracic echocardiography. She developed profound hypotension immediately after valve deployment. Transoesophageal echocardiography (TOE) revealed severe LVOTO and marked mitral regurgitation (MR) due to systolic anterior motion (SAM) of the mitral valve. The simultaneous appearance of AJR abolished atrial contraction, further reducing LV preload. LVOTO and SAM resolved during sinus rhythm, but recurred during AJR. Haemodynamics improved with rapid volume loading, vasoconstrictor administration and continuous right ventricular pacing, thereby reducing obstruction via induced ventricular dyssynchrony. AJR resolved spontaneously following emergence from anaesthesia, and a stable sinus rhythm was maintained. The patient was discharged on postoperative day 12 without recurrence. Discussion This case reports AJR as a novel trigger for suicide LV after TAVI, leading to preload reduction and promoting SAM, LVOTO and MR. Intraoperative TOE provided clear rhythm-dependent imaging of LVOT dynamics. Vigilant rhythm monitoring and prompt, targeted haemodynamic management, including pacing to induce ventricular dyssynchrony, are crucial for prevention and treatment in predisposed patients with small, hypertrophied ventricles with a sigmoid septum.
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Hoshino et al. (2025) studied this question. Accelerated junctional rhythm triggered dynamic left ventricular outflow tract obstruction in an 87-year-old woman post-TAVI, necessitating targeted hemodynamic management.
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