Unexpected suicide left ventricle post-surgical aortic valve replacement requiring veno-arterial extracorporeal membrane oxygenation support despite gold-standard therapy: a case report

Abstract

Background: Suicide left ventricle is a well-documented phenomenon occurring after valve replacement, however, it is most commonly described in the mitral valve replacement (MVR) and transcatheter aortic valve replacement (TAVR) population. Cases within the surgical aortic valve replacement (SAVR) population usually resolve with optimal medical and interventional therapies. We describe a case of left ventricular suicide following SAVR presenting with persistent haemodynamic instability despite currently accepted medical and surgical therapies.

Case summary: A 62-year-old male with severe aortic stenosis presented for SAVR and a MAZE procedure. There were no significant signs of ventricular hypertrophy on preoperative transthoracic echocardiogram (TTE). Intraoperatively, there was mild chordal systolic anterior motion of the mitral valve (SAM) which only occurred when underfilled. During recovery in the intensive care unit, the patient's pulmonary arterial pressures were noted to rise with worsening cardiac output. Subsequent TTE showed severe dynamic left ventricular outflow tract (LVOT) obstruction secondary to SAM. Due to refractory medical management, an alcohol septal ablation was performed. Despite resolution of obstruction, the patient exhibited biochemical signs of systemic hypoperfusion, and thus veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support was initiated. Following 72 h of VA-ECMO support, the patient was weaned with complete resolution of biochemical insults. He was subsequently discharged from the hospital without complication.

Discussion: Compared to the TAVR population, suicide ventricle post-SAVR is comparatively rare. Patients who exhibit persistent impaired cardiac output postoperatively should be investigated rapidly with echocardiography. Furthermore, resolution of a LVOT obstruction state from procedural intervention may not immediately follow with improved cardiac output, and may require further supportive management.

Keywords: Acute heart failure; Aortic valve replacement; Cardiogenic shock; Case report; Echocardiography; Extracorporeal membrane oxygenation.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Figure 1

Preoperative transthoracic echocardiogram. (A) Parasternal short-axis view showing thickened, sclerotic, true bicuspid aortic valve. (B) Evidence of chordal SAM on apical three-chamber view, with increased gain.

Figure 2

Preoperative transthoracic echocardiogram. (A) External institution left ventricular dimension measurements. (B) Retrospective analysis and re-measurement of left ventricular measurements, with increased interventricular septum size. (C) American Society of Echocardiography 2015 guidelines example for left ventricular dimension measurement. (D) Interventricular hypertrophy evident on apical four-chamber view.

Figure 3

Intraoperative transoesophegeal echocardiogram. (A and B) Pre-CPB mid-oeseophageal views showing colour Doppler of aortic and mitral valve function. (C and D) Post-CPB mid-oesophageal short-axis view of Inspiris Resilia aortic valve in both closed and opened conformations.

Figure 4

Postoperative urgent transthoracic echocardiogram. (A) Apical three-chamber view confirming presence of SAM. (B) Apical four-chamber view confirming magnitude of interventricular septum size (overestimated in A4c window).

Figure 5

Comparison transthoracic echocardiograms intra- and post-alcohol septal ablation therapy. (A) Immediate post-ablation view of interventricular septum. (B) Spectral Doppler view with marked peak gradient at time of ablation therapy. (C) D1 post-ablation view of interventricular septum. (D) Spectral Doppler view with improved pressure gradient D1 post-ablation therapy.