Key result
Massive transfusion with procoagulant therapy linked to mitral valve thrombosis and dynamic SAM-like LVOT obstruction.
Why the study?
It was hypothesized that a pathological LVOT obstruction from an etiology other than HOCM could cause comparable hemodynamic instability refractory to inotrope therapy and detectable through echocardiography.
Case Report (n=1)
No
Aggressive procoagulant therapy during massive transfusion can cause mitral valve leaflet thrombosis and dynamic LVOT obstruction, which can be diagnosed via transesophageal echocardiography.
Alternative LVOT obstructions may cause inotrope-refractory instability detectable by echocardiography; leaves open whether this warrants changes in acute HOCM protocols.
BACKGROUND: In cases of hypertrophic obstructive cardiomyopathy (HOCM), the systolic anterior motion of the mitral valve apparatus results in an obstruction of the left ventricular outflow tract (LVOT), which is known as the SAM [systolic anterior motion] phenomenon. Hypothetically, a pathological obstruction of the LVOT of a different etiology would result in a comparable hemodynamic instability, which would be refractory to inotrope therapy, and may be detectable through echocardiography. CASE PRESENTATION: We observed a severely impaired left ventricular function due to a combination of a thrombotic LVOT obstruction and distinctive mitral regurgitation in a 56-year-old Caucasian, female patient after massive transfusion with aggressive procoagulant therapy. Initially, the patient had to be resuscitated due to cardiac arrest after a long-distance flight. The resuscitation attempts in combination with lysis therapy due to suspected pulmonary artery embolism were initially successful but resulted in traumatic liver injury, hemorrhagic shock and subsequent acute respiratory distress syndrome (ARDS). Oxygenation was stabilized with veno-venous extracorporeal membrane oxygenation (ECMO), but the hemodynamic situation deteriorated further. Transesophageal echocardiography (TEE) showed a massive, dynamic LVOT obstruction. Two thrombi were attached to the anterior leaflet of the mitral valve, resulting in a predominantly systolic obstruction. Unfortunately, the patient died of multiple-organ failure despite another round of lysis therapy and escalation of the ECMO circuit to a veno-venoarterial cannulation for hemodynamic support. CONCLUSION: Massive transfusion with aggressive procoagulant therapy resulted in mitral valve leaflet thrombosis with dynamic, predominantly systolic LVOT obstruction, comparable to the SAM phenomenon. The pathology was only detectable with a TEE investigation.
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Skrypnikov et al. (2021) conducted a case report in Hemorrhagic shock and dynamic LVOT obstruction (n=1). Aggressive procoagulant therapy and massive transfusion was evaluated. Massive transfusion with aggressive procoagulant therapy resulted in mitral valve leaflet thrombosis with dynamic, predominantly systolic LVOT obstruction, comparable to the SAM phenomenon.
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