Key result
Cardiac myosin inhibition with load-directed therapy resolves post-TAVI dynamic LVOT obstruction over 4 months.
Why the study?
Relieving severe aortic stenosis can unmask previously concealed dynamic left-ventricular outflow-tract obstruction, but clinical recognition and management strategies are not well described.
Case Report (n=1)
Relief of fixed afterload by TAVI can unmask severe dynamic LVOT obstruction, requiring recognition and load-directed management (avoiding inotropes) and highlighting a potential novel use for cardiac myosin inhibitors.
Answers are grounded in this paper and cite their sources.
Post-TAVI hypotension in hypertrophic patients warrants screening for unmasked dynamic LVOT obstruction; this case leaves open targeted load-directed strategies.
Structured Abstract Background Relieving the fixed afterload of severe aortic stenosis can unmask a previously concealed dynamic outflow-tract obstruction. Case summary A 69-year-old man with severe aortic stenosis (valve area 0.65 cm2; 109/64 mmHg), mild concentric hypertrophy (septum 15 mm) and no baseline systolic anterior motion (SAM) underwent transcatheter aortic valve implantation (TAVI). The invasive peak-to-peak gradient fell from 64 to 7 mmHg, but echocardiography immediately afterwards showed new SAM and severe dynamic left-ventricular-outflow-tract (LVOT) obstruction (170/67 mmHg) with hypotension. Treatment was load-directed (volume expansion, avoidance of vasodilators and inotropes, beta-blockade), with a cardiac myosin inhibitor as an adjunct. Over four months the resting LVOT gradient fell to 22/13 mmHg and the provoked peak to 29 mmHg, with SAM no longer seen and preserved ejection fraction. Discussion Recognising this load-dependent obstruction during the procedure and restoring loading, rather than escalating inotropes, is the key lesson.
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Gao et al. (2026) conducted a case report in Severe aortic stenosis with post-TAVI dynamic left-ventricular outflow-tract obstruction (n=1). Load-directed therapy and cardiac myosin inhibitor was evaluated on LVOT gradient and systolic anterior motion (SAM). Load-directed treatment combined with a cardiac myosin inhibitor successfully managed dynamic left-ventricular outflow-tract obstruction unmasked by TAVI, resolving systolic anterior motion over 4 months.
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