Left ventricular outflow obstruction at multiple levels: Occurrence in a single patient

Combined forms of left ventricular outflow obstruction are being recognized with increasing frequency. A patient who had coarctation of the aorta, valvular aortic stenosis, and fixed and dynamic subvalvular obstruction is described. The importance of recognizing multiple levels of obstruction in such patients is emphasized.     

A Case of Aortic Stenosis and Hypertrophic Cardiomyopathy

A patient with severe aortic valvular stenosis and coexisting obstructive hypertrophic cardiomyopathy, in whom diagnostic difficulties and management dilemmas arose, is presented. The complex issues involved in such a combination are discussed.     

Isolated Supravalvar Aortic Stenosis Without William's Syndrome

Supravalvular aortic stenosis, characterized by narrowing of the ascending aorta above the valve, is the least common form of left ventricular outflow tract obstruction and is usually associated with William''s syndrome. We present a case of a 27-year-old male with isolated supravalvar aortic stenosis (SVAS) presenting with heart failure. This case underscores the fact that in rare cases sporadic SVAS can occur in isolation without the classic findings of William''s syndrome and highlighting the importance of integration of clinical and echocardiographic recognition for definitive management.     

Subaortic stenosis missed by invasive hemodynamic assessment

We present a case of 61-year-old man that was evaluated for possible aortic stenosis but did not show a left ventricular outflow gradient on invasive assessment in the catheterization laboratory. Transthoracic echocardiography showed subaortic stenosis secondary to a discrete membranous structure in the left ventricular outflow tract. This is the first case in the literature of a patient with discrete subaortic stenosis missed by invasive hemodynamic assessment.     

Obstruction of Left Atrial Filling by a Large Descending Thoracic Aortic Aneurysm Detected by Pulsed Doppler Echocardiography

We describe the echocardiographic findings of extrinsic compression of the left atrium by a large aneurysm of the descending aorta. Pulsed Doppler echocardiography demonstrated increased velocity at the junction of left atrium and pulmonary vein suggesting obstruction of left atrial filling.     

The Usefulness of Transesophageal Echocardiography in the Surgical Management of Older Children with Subaortic Stenosis

Subaortic stenosis is a complex lesion that often presents in older children and adolescents. A clear depiction of the lesion is required for optimization of surgery. Due to the large size of these patients, is not always possible from surface echocardiography. Intraoperative multiplane echocardiography (MTEE) has been performed at our institute in older children for several different congenital heart lesions including many patients with subaortic stenosis. A retrospective analysis of our experience with MTEE in patients with subaortic stenosis was performed to assess its usefulness in the preoperative diagnosis and postoperative assessment of repair. Our results show that intraoperative MTEE was useful preoperatively by correcting or confirming suspected diagnosis, and giving additional details of the lesion in many patients. Postoperatively, MTEE was highly useful in the assessment of repair. We strongly recommend the use of intraoperative MTEE in older children and adolescents with subaortic stenosis.     

False Aneurysm of the Aortic Root and Right Ventricular Outflow Obstruction

Aortic root abscess often complicates the course of aortic valve endocarditis. In severe cases, left ventricular-aortic discontinuity may occur, providing challenging technical problems for the surgeon. Moreover, surgical intervention sometimes takes place in a semi-emergency context, and the patches and prosthesis are sutured into friable tissues and subjected to high systemic pressures. Subsequently, paravalvular leaks and prosthesis dehiscence are not uncommon; postoperative false aneurysm of the aortic root is a much more unusual complication. We report one case of right ventricular outflow obstruction that occurred after surgical treatment of an aortic root abscess. Echocardiographic data were useful, but magnetic resonance imaging provided valuable information about the anatomic extent of the cavity.     

Left Atrial Systolic Force and Outcome in Asymptomatic Mild to Moderate Aortic Stenosis

Background and Aims: In patients with chronic pressure overload due to hypertension or aortic valve stenosis (AS), higher left atrial systolic force (LASF) is associated with a high‐risk cardiovascular (CV) phenotype. We tested LASF as prognostic marker in patients with AS. Methods: We used baseline and outcome data from 1,566 patients recruited in the Simvastatin and Ezetimibe in AS (SEAS) study evaluating the effect of placebo‐controlled simvastatin and ezetimibe treatment on CV events. The primary outcome was a composite of major CV events, including CV death, aortic valve replacement, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure caused by progression of AS, coronary artery bypass grafting, percutaneous coronary intervention, and nonhemorrhagic stroke. LASF was calculated by Manning's method. High LASF was defined as >95th percentile (50 Kdynes/cm²) of the distribution within the study population. Results: During 4.3 years of follow‐up, a major CV event occurred in 38 of 78 patients with high LASF (49%) and in 513 of 1,488 (34%) with normal LASF (P = 0.01). In multivariate Cox regression analysis, high LASF predicted higher rate of major CV events (Hazard ratio 1.43 [95% confidence interval 1.01–2.03] independent of aortic valve area and LV mass index. A simple risk score including absence or presence of these three variables allowed risk stratification into low, intermediate, high and very high risk for major CV events during follow‐up (22%, 28%, 38%, and 53%, respectively). Conclusions: Higher LASF provides additional prognostic information in patients with asymptomatic mild‐to‐moderate AS.     

Reduced Left Ventricular Ejection Fraction in Patients With Aortic Stenosis

Background

Left ventricular ejection fraction (LVEF) is reduced in a subset of patients with severe aortic stenosis (AS).

Left Ventricular Outflow Tract Obstruction After Myocardial Infarction Due to a Hyperdynamic Basal Septum

Acquired left ventricular outflow (LVOT) obstruction may occur following mitral valve repair or replacement. We describe a case where following a large myocardial infarction the hyperdynamic basilar septum was the cause of LVOT.     

Noninvasive Evaluation of Membranous Subaortic Stenosis: Complimentary Roles of Echocardiography and Computed Tomographic Angiography

A 29‐year‐old Ethiopian woman that was referred to the Wisconsin Heart Hospital for treatment of subaortic stenosis, diagnosed 4 years earlier, in Ethiopia, using transthoracic echocardiography. Preoperative evaluation included transesophageal echocardiography, which showed severe membranous subaortic stenosis with a mean outflow gradient of 70 mmHg. Cardiac computed tomographic angiography also demonstrated a subaortic membrane, and additionally showed normal epicardial coronary arteries. The patient underwent uneventful surgical resection of the subaortic membrane without undergoing cardiac catheterization. (Echocardiography 2010;27:E34‐E35)     

Stress Echocardiography in Aortic Stenosis

Stress interventions have been classically combined with cardiac catheterization recordings to understand the hemodynamic principles of valvular stenosis. Indices of aortic stenosis such as pressure gradient and valve area were based on simple hydraulic principles and have proved to be clinically useful for patient management during a number of decades. With the advent of Doppler echocardiography, these hemodynamic indices can be readily obtained noninvasively. Abundant evidence obtained using exercise and pharmacological stress echocardiography has demonstrated that the assumptions of classic hemodynamic models of aortic stenosis were wrong. Consequently, it is recognized that conventional indices may be misleading indicators of aortic stenosis significance in particular clinical situations. To improve diagnostic accuracy, several alternative hemodynamic models have been developed in the past-few years, including valve resistance and left ventricular stroke work loss, among others. Nevertheless, these more-accurate indices should be obtainable noninvasively and need to demonstrate greater diagnostic and prognostic power than conventional indices; preliminary data suggest such superiority. Stress echocardiography is well established as the tool of choice for testing hypothesis and physical models of cardiac valve function. Although the final role of alternative indices is not yet well established, the new insights into valvular hemodynamics provided by this technique may change the clinical assessment of aortic stenosis.     

The use of MitraClip to prevent posttranscatheter aortic valve replacement left ventricular “suicide”

Patients with concomitant severe aortic stenosis (AS) and left ventricular outflow tract (LVOT) obstruction undergoing transcatheter aortic valve replacement (TAVR) are at risk for hemodynamic collapse due to a sudden decrease in afterload causing worsening LVOT obstruction. We present a case of an 88-year-old female with symptomatic, severe AS, and LVOT obstruction with systolic anterior motion (SAM) of the mitral leaflet in whom alcohol septal ablation was contraindicated secondary to a chronic total occlusion of the right coronary artery that filled retrograde via septal collaterals. MitraClip at the time of TAVR was successfully performed to treat SAM with subsequent stabilization of LVOT gradients despite treatment of the patient's AS. This novel approach may represent a feasible option to prevent hemodynamic complications after TAVR in patients with significant LVOT obstruction secondary to SAM and AS.