Suicidal Left Ventricle After Transcatheter Aortic Valve Replacement Causing Cardiogenic Shock

Figures

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  Figure 1. Baseline Transthoracic Echocardiography Demonstrating Severe Calcific Aortic Stenosis and Concentric Left Ventricular Remodeling (A and B) Long-axis views showing severe aortic valve calcification with severe aortic valve stenosis and concentric LV hypertrophy (red arrows). (C) Continuous-wave Doppler demonstrating elevated transvalvular gradients consistent with severe aortic stenosis. These findings establish the hemodynamic severity and chronic pressure overload state prior to intervention. LA = left atrium; LV = left ventricle; RV = right ventricle.

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  Figure 2. Fluoroscopic Guidance During Transcatheter Aortic Valve Replacement (A) Baseline fluoroscopic image showing severe calcification of the native aortic valve. (B) Positioning and deployment of the transcatheter valve across the native annulus under fluoroscopic guidance. (C) Final expansion of the bioprosthetic valve with appropriate positioning and full device apposition. These procedural images illustrate key steps for optimal valve implantation and procedural success.

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  Figure 3. Postprocedural Transthoracic Echocardiography Demonstrating Dynamic Intraventricular Obstruction and Subsequent Recovery After Targeted Management (A) Apical 4-chamber view showing marked reduction in left ventricular cavity size with hyperdynamic contraction (solid green line). (B) Parasternal long-axis view demonstrating near-complete systolic cavity obliteration, consistent with dynamic intraventricular obstruction (solid green line). (C) Follow-up long-axis view after medical management demonstrating improvement in left ventricular filling and resolution of cavity collapse. (D) Doppler evaluation showing normalization of the dynamic intraventricular gradient following hemodynamic stabilization. These findings highlight a reversible complication following transcatheter aortic valve replacement requiring prompt recognition and tailored therapy. LA = left atrium; RA = right atrium.

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  Figure 4. Recognition and Management Algorithm for Suicidal Left Ventricle After Transcatheter Aortic Valve Replacement The algorithm summarizes the evaluation and treatment of patients with post-TAVR hemodynamic collapse. Early echocardiography is essential to exclude procedural complications and identify findings suggestive of suicidal LV, including a small hyperdynamic ventricle, systolic anterior motion, dynamic left ventricular outflow tract (LVOT) obstruction with a late-peaking “dagger-shaped” Doppler profile, and reduced stroke volume. Management includes discontinuation of inotropes, volume expansion, vasopressor support to maintain afterload, heart rate control when indicated, and serial echocardiographic monitoring. BP = blood pressure; IV = intravenous.