Case Report
Anteroapical Stunning and Left Ventricular Outflow Tract Obstruction

https://doi.org/10.4065/76.1.79Get rights and content

Dynamic left ventricular outflow tract (LVOT) obstruction is typically observed in the setting of hypertrophic cardiomyopathy. It has also been reported with concentric LV hypertrophy, excessive sympathetic stimulation, and acute myocardial infarction. We describe 3 patients with chest discomfort after emotional stress, who had pronounced abnormalities on electrocardiograms, insignificant obstructive coronary disease and hemodynamic instability with LVOT obstruction, and regional wall motion abnormalities. Suppression of contractility with β-blockers resulted in resolution of the gradient and in clinical improvement. On follow-up, functional recovery was excellent, and ventricular function had normalized. The conditions and mechanisms that may produce this sequence of events are discussed. The most probable scenario is that an acute ischemic insult secondary to vasospasm, LV stunning, and acute geometric remodeling produced a substrate for LVOT obstruction that was exacerbated by basal LV hypercontractility. The importance of this observation is that routine treatment of cardiogenic shock cannot be used and that conservative management results in excellent prognosis.

Section snippets

Case 1

A 62-year-old woman with hypertension presented with a 24-hour history of anterior chest and throat discomfort after an argument with her daughter. Findings on physical examination showed tachycardia. An electrocardiogram (ECG) showed diffuse symmetrical T-wave inversion with QT prolongation (QTc, 570 milliseconds). In the ensuing 12 hours, she developed progressive cardiovascular compromise with hypotension and pulmonary edema. A new harsh 3/6 systolic murmur was noted over the apex and left

DISCUSSION

Our 3 female patients had new-onset chest discomfort, hemodynamic instability due to LVOT obstruction (Figure 1, Figure 2), focal wall motion abnormalities, and abnormalities on ECGs (Figure 3) in the absence of epicardial coronary artery disease or HCM. Suppression of ventricular contractility with β-blockers resulted in resolution of the LVOT gradient (Figure 4) and clinical improvement. On follow-up, the wall motion and LV function had normalized.

The scenarios that may conceivably produce

Cited by (186)

  • Iatrogenic corticosteroids induced Takotsubo cardiomyopathy

    2018, Cardiovascular Revascularization Medicine
View all citing articles on Scopus
View full text