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[Left ventricular wall motion mimicking stunned myocardium in hypertrophic obstructive cardiomyopathy with normal
M Morita1, K Kawakami, S Asakuma
1First Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya.
Insights
A patient experienced cardiogenic shock due to hypertrophic obstructive cardiomyopathy. Prompt treatment resolved left ventricular wall motion abnormalities and systolic anterior motion, suggesting outflow tract obstruction as the cause.
Area of Science:
- Cardiology
- Cardiovascular Medicine
Background:
- A 63-year-old woman presented with cardiogenic shock following chemotherapy for uterine cancer.
- Initial assessment revealed hypertrophic obstructive cardiomyopathy and significant left ventricular wall motion abnormalities.
Observation:
- Coronary arteriography excluded coronary artery disease.
- Echocardiography and left ventriculography demonstrated resolution of wall motion abnormalities and systolic anterior motion (SAM) by day 21.
- Left ventricular apical systolic pressure was markedly elevated at 200 mmHg on admission.
Findings:
- Transient ventricular wall motion abnormalities and SAM resolved with medical management.
- Findings suggest left ventricular outflow tract obstruction, not acute myocardial ischemia, as the primary cause.
- The Venturi effect, exacerbated by hypovolemia, and papillary muscle dynamics likely contributed to SAM.
Implications:
- This case highlights the potential for severe left ventricular outflow tract obstruction to mimic ischemic events.
- Understanding the mechanisms of SAM is crucial for managing complex cardiomyopathies.
- Effective treatment of obstructive cardiomyopathy can lead to rapid functional recovery.
Abstract:
A 63-year-old woman was admitted to the coronary care unit of Hyogo College of Medicine because of cardiogenic shock. She previously had been hospitalized in the Gynecology Department for the treatment of recurrent uterine cancer. She had poor appetite due to chemotherapy which was given for 10 days prior to her admission. On admission, echocardiography and cardiac catheterization revealed hypertrophic obstructive cardiomyopathy and extensive left ventricular wall motion abnormalities. Coronary arteriography showed no coronary artery disease. Left ventriculography as well as echocardiography performed on the 21st post-admission day revealed that the wall motion abnormalities had completely resolved and the systolic anterior motion of the mitral valve (SAM) was no longer evident. The systolic pressure at the apex of the left ventricle was 200 mmHg on admission. The increased ventricular pressure and the simultaneous resolution of the wall motion abnormality and SAM suggest that marked obstruction of the left ventricular outflow tract is more likely to be involved in transient ventricular wall motion abnormality rather than acute myocardial ischemia. The mechanism of the SAM in the present case seemed to be related to a Venturi effect which was augmented by the decreased preload due to hypovolemia. In addition, papillary muscle contraction seemed to pull the mitral valve toward the interventricular septum during systole.