Unusual case of post-operative suicide left ventricle in a patient with dynamic LVOT obstruction

Suicide left ventricle (SLV) is a well-documented complication after surgical or transcatheter aortic valve replacement. We present an unusual case of a patient who developed left ventricular outflow tract (LVOT) obstruction with a native aortic valve, resulting in SLV after routine non-cardiac surgery. A 45-year-old male presented to the emergency room with abdominal pain and was diagnosed with acute cholecystitis. The patient had a known medical history of severe left ventricular hypertrophy. The patient underwent an uncomplicated laparoscopic cholecystectomy. Post-operatively, he went into shock during weaning from anesthesia. He was started on norepinephrine followed by epinephrine and vasopressin, without much improvement. Increasing doses of vasopressors failed to improve the patient's hemodynamics. A presumptive diagnosis of SLV was made. This was secondary to hemodynamic collapse due to vasoplegia from anesthesia, worsening LVOT obstruction and subsequent right ventricular failure. Despite being in shock, the patient was taken off pressors and started on esmolol infusion to increase diastolic filling and epoprostenol to decrease the right ventricle strain by pulmonary vasodilation. The patient responded promptly to these measures. A repeat echocardiogram showed a significant improvement in right and left ventricular function.

Suicide left ventricle (SLV) is commonly seen in patients post aortic valve replacement. It presents as shock which does not respond to pressors and instead is treated by beta-blockers. Our patient developed SLV pathophysiology despite having native aortic valve. He developed shock which did not improve with pressors but responded to esmolol. This emphasizes the importance of fluid management in patients with severe left ventricular outflow tract obstruction. It also gives a different perspective to managing shock in such patients who are not responding to pressors.