Silent Threats of the Heart: A Case Series and Narrative Review on Suicide Left Ventricle Post-Aortic Valve Replacement in Patients with Dynamic LVOT Obstruction and Aortic Stenosis

Figures

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  Figure 1. Transthoracic and transesophageal echocardiography in an 87-year-old woman with paradoxical low-flow low-gradient aortic stenosis. Left panel. PLAX view (upper) and 4-chamber view (lower). IVS telediastolic diameter = 20 mm, LVEDVi = 31 mL/m2. Central panel. Aortic valve peak velocity of 3.6 m/s (upper) with a mean gradient of 28 mmHg and a dynamic LVOT gradient (lower) of 54 mmHg after the Valsalva maneuver. Right panel after TAVI. SAM of the anterior mitral leaflet (upper, red arrow) by TEE causing severe mitral regurgitation. IVS: interventricular septum. LVEDVi: left ventricular end-diastolic volume indexed. LVOT: left ventricular outflow tract. SAM: systolic anterior motion.

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  Figure 2. Transthoracic and transesophageal echocardiography in an 86-year-old woman before and after aortic valve stenosis percutaneous treatment and transcatheter alcohol septal ablation. Left panel: PLAX view (upper) and 4-chamber view (lower); IVS = 26 mm; LVEDVi = 45 mL/mq. Central panel: aortic valve peak velocity of 5.8 m/s (upper) with a mean gradient of 77 mmHg and dynamic LVOT gradient (lower) of 65 mmHg. Right panel—after TAVI and alcohol septal ablation: dynamic LVOT gradient (upper) of 20 mmHg but evidence of residual SAM of the anterior mitral leaflet (lower) by TEE. IVS: interventricular septum. LVEDVi: left ventricular end-diastolic volume indexed. LVOT: left ventricular outflow tract. SAM: systolic anterior motion. TAVI: transcatheter aortic valve implantation.

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  Figure 3. Transthoracic echocardiography of a 79-year-old woman before and after surgical aortic valve replacement and septal myectomy. Left panel. PLAX view (upper) and 4-chamber view (lower). IVS telediastolic diameter = 15 mm; LVEDVi 27 mL/m2. Central panel. Aortic valve peak velocity of 4.5 m/s (upper) with a mean gradient of 51 mmHg and dynamic LVOT gradient (lower) of 42 mmHg after the Valsalva maneuver. Right panel: after cardiac surgery. 4-chamber view (upper) and dynamic LVOT gradient of 11 mmHg (lower) after surgical aortic valve replacement. IVS: interventricular septum. LVEDVi: left ventricular end-diastolic volume indexed. LVOT: left ventricular outflow tract.

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  Figure 4. Transthoracic echocardiography of an 80-year-old man before and after aortic valve percutaneous replacement and pacemaker implantation. Left panel. PLAX view (upper) and 4-chamber view (lower). IVS telediastolic diameter = 18 mm; LVEDVi = 54 mL/m2. Central panel. Aortic valve peak velocity of 4.5 m/s (upper) with a mean gradient of 50 mmHg and dynamic LVOT gradient (lower) of 45 mmHg after the Valsalva maneuver. Right panel after TAVI. Increased dynamic LVOT gradient after TAVI (upper) of 65 mmHg after the Valsalva maneuver, which is reduced after pacemaker implantation (lower). IVS: interventricular septum. LVEDVi: left ventricular end-diastolic volume indexed. LVOT: left ventricular outflow tract. TAVI: transcatheter aortic valve implantation.

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  Figure 5. Pathophysiology of suicide left ventricle in patients with dynamic left ventricular outflow tract (LVOT) obstruction and aortic stenosis.

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  Figure 6. Red flags of suicide left ventricle and proposed strategy for hemodynamic optimization in patients with aortic stenosis and dynamic left ventricle outflow tract (LVOT) obstruction.