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Published on: October 28, 2020
Diverse geometric changes related to dynamic left ventricular outflow tract obstruction without overt hypertrophic
Jung-Joon Cha, Hyemoon Chung, Young Won Yoon1
1Division of Cardiology, Heart Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea. DRCLIFF@yuhs.ac.
Insights
Dynamic left ventricular outflow tract (LVOT) obstruction (DLVOTO) in older adults stems from various causes, with prominent papillary muscles presenting unique features. This condition may be managed with medications to reduce pulmonary pressure.
Area of Science:
- Cardiology
- Cardiovascular Imaging
- Geriatric Medicine
Background:
- Dynamic left ventricular outflow tract obstruction (DLVOTO) is often observed in elderly individuals without overt hypertrophic cardiomyopathy (HCM).
- Investigating the geometric changes and clinical characteristics associated with DLVOTO in this population is crucial.
- Understanding the diverse etiologies of DLVOTO is essential for appropriate patient management.
Purpose of the Study:
- To investigate the geometric changes associated with dynamic left ventricular outflow tract obstruction (DLVOTO) in older adults.
- To evaluate the clinical characteristics of patients with DLVOTO.
- To identify distinct patient subgroups within DLVOTO, such as those with prominent papillary muscles.
Main Methods:
- A study of 168 patients with DLVOTO (trans-LVOT peak pressure gradient >30 mmHg at rest or with Valsalva maneuver).
- Exclusion of patients with classical HCM, acute myocardial infarction, stress-induced cardiomyopathy, or unstable hemodynamics.
- Classification of patients into groups based on septal morphology (sigmoid septum, sigmoid septum with hypertrophy) and papillary muscle size or LV cavity dimensions.
Main Results:
- Patients with prominent papillary muscles were younger and had distinct hemodynamic profiles (higher S', lower E/e').
- Higher peak trans-LVOT pressure gradients correlated with increased E/e', systolic blood pressure, relative wall thickness, and pulmonary arterial systolic pressure.
- Multivariate analysis revealed resting trans-LVOT pressure gradient correlated with pulmonary arterial pressure, independent of other factors.
Conclusions:
- Dynamic left ventricular outflow tract obstruction (DLVOTO) arises from diverse causes.
- Patients with prominent papillary muscles exhibit unique clinical and geometric characteristics.
- Medications aimed at relieving DLVOTO may help reduce pulmonary pressure in this specific patient group.
Background:
Dynamic left ventricular (LV) outflow tract (LVOT) obstruction (DLVOTO) is not infrequently observed in older individuals without overt hypertrophic cardiomyopathy (HCM). We sought to investigate associated geometric changes and then evaluate their clinical characteristics.
Methods:
A total of 168 patients with DLVOTO, which was defined as a trans-LVOT peak pressure gradient (PG) higher than 30 mmHg at rest or provoked by Valsalva maneuver (latent LVOTO) without fixed stenosis, were studied. Patients with classical HCM, acute myocardial infarction, stress induced cardiomyopathy or unstable hemodynamics which potentially induce transient-DLVOTO were excluded.
Results:
Their mean age was 71 ± 11 years and 98 (58%) patients were women. Patients were classified as pure sigmoid septum (n = 14) if they have basal septal bulging but diastolic thickness less than 15 mm, sigmoid septum with basal septal hypertrophy for a thickness ≥15 mm (n = 85), prominent papillary muscle (PM) (n = 20) defined by visually large PMs which occluded the LV cavity during systole or 1/2 LVESD, or as having a small LV cavity with concentric remodelling or hypertrophy (n = 49). The prominent PM group was younger, had a higher S' and lower E/e' than other groups. In all groups, a higher peak trans-LVOT PG was related (p < 0.10) to higher E/e', systolic blood pressure, relative wall thickness, and pulmonary arterial systolic pressure. In multivariate analysis, resting trans-LVOT PG correlated to pulmonary arterial pressure (ß = 0.226, p = 0.019) after adjustment for systolic blood pressure, relative wall thickness, and E/e'.
Conclusions:
DLVOTO develops from various reasons, and patients with prominent PMs have distinct characteristics. We suggest to use DLVOTO-relieving medication might reduce pulmonary pressure in this group of patients.
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