Obstructive Shock From Suicide Left Ventricle After Transcatheter Aortic Valve Replacement

Dynamic left ventricular obstruction, often referred to as suicide left ventricle, is an uncommon and potentially fatal cause of obstructive shock after transcatheter aortic valve replacement (TAVR).

An 89-year-old man with severe symptomatic aortic stenosis, severe concentric hypertrophy, and a small left ventricular cavity underwent transfemoral TAVR. Fifteen minutes after deployment of a 29-mm self-expanding valve, he developed hemodynamic collapse. Multimodality assessment excluded major procedural complications. At 30 minutes, echocardiography confirmed dynamic left ventricular outflow tract obstruction, with a peak gradient of 86 mm Hg, systolic anterior motion, mild mitral regurgitation, and an associated midventricular gradient. Volume expansion, phenylephrine, and propranolol reduced the gradient to 12 mm Hg, with shock resolution within 24 hours.

Early echocardiography identifies this obstructive physiology and redirects therapy toward preload and afterload augmentation, withdrawal of beta-adrenergic stimulation, and beta-blockade.

Dynamic left ventricular outflow tract obstruction should be suspected in early post-TAVR shock.