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PubMed1989

Fatal acute left ventricular outflow obstruction due to interventricular septal haematoma--diagnosis by transoesophageal echocardiography.

We describe a case of fatal left ventricular outflow obstruction detected by intraoperative transoesophageal echocardiography. This resulted from acute haematoma formation within the interventricular septum following internal mammary artery grafting to the left anterior descending coronary artery. This unusual case highlights the emerging role of transoesophageal echocardiography in the diagnosis and management of the complications of cardiac surgery.

Echocardiography, Doppler↗
PubMed1995

[Surgical treatment of transposition of the great arteries with intact ventricular septum associated with left ventricular outflow obstruction].

Thirteen patients have undergone surgical treatment for transposition of the great arteries (TGA) with intact ventricular septum (IVS) associated with left ventricular outflow obstruction (LVOTO) in our institute. Ages at operation ranged from three months to six years (mean 9.2 +/- 4.7 months). Of these patients, seven had dynamic type LVOTO (group I), and six had organic LVOTO (group II). Preoperative left ventricular end-diastolic volume was significantly smaller in group II (78 +/- 13% of normal) than control group (135 +/- 53% of normal). Preoperative pressure gradient between the pulmonary artery and left ventricle was significantly greater in group II (55.8 +/- 3.2 mmHg) than group I (35.2 +/- 3.9 mmHg). In group I, II patients underwent two-stage ASO, the other 5 patients underwent Senning operation. The reason for the Senning operation were era before introduction of ASO in our institute (1983) or unsuccessful training of the left ventricle. In group II, all but one patient underwent Senning operation, the other underwent a successful Fontan operation with Damus anastomosis because of too small left ventricle (LVEDV: 49% of normal). Techniques to correct LVOTO at the definitive operation included ventriculotomy (n = 4) and pulmonary valvotomy (n = 2). One patients in group II underwent a Fontan operation with Damus anastomosis due to an underdeveloped left ventricle (LVEDV: 49% of normal). There was no early or late death. The postoperative pressure gradients disappeared or reduced to trivial levels in all patients. At present no LVOTO has developed in any of the patients.

Cardiac Surgical Procedures↗
PubMed1989

Effect of surgical reduction of left ventricular outflow obstruction on hemodynamics, coronary flow, and myocardial metabolism in hypertrophic cardiomyopathy.

To assess the impact of operative reduction of left ventricular outflow obstruction in hypertrophic cardiomyopathy, measurements of great cardiac vein flow, oxygen and lactate content, left ventricular pressures, and cardiac index were measured at rest and during pacing stress in 20 consecutive patients (13, myotomy-myectomy; six, mitral valve replacement; one, both myotomy-myectomy and mitral valve replacement) who underwent both preoperative and postoperative studies. All had angiographically normal epicardial coronary arteries. Operation resulted in reduction in outflow gradient (64 +/- 38 to 4 +/- 7 mm Hg, p less than 0.001) and in left ventricular systolic pressure (186 +/- 32 to 128 +/- 22 mm Hg, p less than 0.001) and was associated with reduction in great cardiac vein flow (101 +/- 26 to 78 +/- 16 ml/min, p less than 0.001) and oxygen consumption in the anterior left ventricle and septum (11.9 +/- 4.1 to 8.4 +/- 1.9 ml O2/min, p less than 0.001) in the basal state. During rapid atrial pacing, 13 of 20 patients experienced chest pain postoperatively, whereas all 20 developed chest pain during preoperative pacing, with an improvement in pacing anginal threshold (or heart rate 150 if no chest pain was experienced) of 16 +/- 18 beats/min (p less than 0.001). The peak great cardiac vein flow (161 +/- 41 to 131 +/- 45 ml/min, p less than 0.025) and myocardial oxygen consumption (19.4 +/- 6.1 to 14.3 +/- 5.5 ml O2/min, p less than 0.005) during pacing, which correlated directly with the severity of the basal left ventricular gradient (p = 0.011 and p = 0.002, respectively), were also reduced by surgery. Lactate metabolism during pacing changed from net production before surgery to net consumption after operation (-17 +/- 47.6 to 4.4 +/- 29.8 mumol/min, p less than 0.01), with six of 20 patients producing lactate after surgery compared with 13 of 20 before surgery (p = 0.06). The six patients with the highest peak great cardiac vein flow (greater than 175 ml/min) during preoperative pacing had greater symptom and metabolic benefit during pacing after surgery compared with the 14 patients with lower peak coronary flow. Postpacing left ventricular end-diastolic pressure (30 +/- 7 to 23 +/- 7 mm Hg, p less than 0.001) and pulmonary artery wedge pressure (24 +/- 6 to 20 +/- 5, p less than 0.001) were reduced after surgery.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1992

Intravascular stent prosthesis for right ventricular outflow obstruction.

OBJECTIVES: This study was designed to assess the impact of implantation of balloon-expandable stents on right ventricular outflow obstruction in children with congenital heart disease. BACKGROUND: Intravascular stenting has been established as a useful treatment in adults with coronary and peripheral vascular disease. Its application in the treatment of infants and children with pulmonary, systemic and right ventricular conduit obstruction resistant to balloon angioplasty is limited. METHODS: A total of 24 stainless steel stents were implanted in 17 patients. Five stents were placed within right ventricular to pulmonary artery conduits, 17 in branch pulmonary arteries and 1 in an aortopulmonary collateral vessel. Follow-up time has ranged from 1 to 14 months, with 6 patients having hemodynamic and angiographic studies greater than 1 year after stent placement. The mean age at implantation was 7.4 +/- 5.6 years and the mean weight 33 +/- 16 kg. RESULTS: Optimal stent position was obtained in 22 of 24 implantations. In one patient the stent slipped from the delivery balloon and was left positioned in the inferior vena cava. No embolization or thrombotic event has been documented. Among patients with right ventricular to pulmonary artery conduit obstruction, the gradient was immediately reduced from 85 +/- 30 mm Hg to 35 +/- 20 mm Hg after stent implantation; however, three patients required conduit replacement because of persistent obstruction with elevated right ventricular pressures (82 +/- 16 mm Hg). In 10 of 11 patients with pulmonary artery stenosis, clinical improvement was noted in association with enlargement of vessel diameter by 92% +/- 90% (range 17% to 355%) and the gradient reduction of 22 +/- 24 mm Hg to 3 +/- 4 mm Hg. CONCLUSIONS: These data support the view that intravascular stenting will become an important adjunct in the management of children with congenital heart disease.

Child↗
PubMed2000

Initial experience using the Palmaz Corinthian stent for right ventricular outflow obstruction in infants and small children.

The original Palmaz balloon expandable stent has been used extensively for the treatment of vascular stenoses in older children and young adults. Placement of the Palmaz stent in infants and small children, however, is limited by stent inflexibility, large delivery sheath size, and concerns about creating fixed obstructions after the placement of small diameter stents in growing patients. New Palmaz Corinthian stents were placed through 6 French sheaths in four high-risk patients with postoperative right ventricular outflow obstruction. Patients were not considered candidates for surgical repair. Median patient age and weight were 17 months (range 5-32 months) and 7.7 kg (range 4.6-11.1 kg), respectively. Median fluoroscopy time was 58.2 min (range 55.2-172 min). No complications were encountered. In each case, successful stent placement was achieved, and surgery with cardiopulmonary bypass was avoided. Palmaz Corinthian stents are more flexible, require a smaller delivery sheath, have equal or increased radial strength, and can be maximally expanded to a greater cross sectional area when compared to the original Palmaz stent. These characteristics make the Palmaz Corinthian stent a reasonable alternative for use in a select group of infants and small children who are not candidates for surgical repair of postoperative right ventricular outflow obstruction.

Angioplasty, Balloon↗
PubMed1985

[Mechanism of systolic anterior motion and left ventricular outflow obstruction in hypertrophic obstructive cardiomyopathy].

Two-dimensional echocardiographic studies were performed for 22 patients with asymmetric septal hypertrophy and systolic anterior motion (SAM) of the mitral valve to clarify the mechanism of SAM and left ventricular outflow obstruction. The long-axis view of the left ventricle showed that a distal portion of the anterior mitral leaflet became surplus when the mitral valve was closed in 15 of 16 patients with SAM-septal contact and in four of six patients without it. In these patients, the mitral leaflet coaptation was displaced anteriorly, and/or the anterior leaflet was elongated, showing an anterior motion. In an unusual patient with SAM-septal contact, a distal portion of the long posterior mitral leaflet was surplus. The remaining two patients without SAM-septal contact had a rather widely coapted portion of the mitral leaflets. The distal surplus portion and the coapted portion of the mitral valve were displaced anteriorly prior to the onset of ejection, and moved forward and protruded into the outflow tract more rapidly and more excessively than the papillary muscles during early to mid systole in all patients. Then, the distal mitral valve and the chordae tendineae adopted the configuration of an inverted V in mid systole. The tip of the surplus leaflet contacted the interventricular septum in patients with SAM-septal contacts. In the short-axis view of the left ventricle, the central portion of the distal mitral valve moved forward excessively and bent like an inverted U during early to mid systole. Therefore, SAM of the distal mitral valve is thought to be caused by the hydrodynamic force generated by the ejection flow. This force is supposed to be not only due to the Venturi effect, but is more properly understood as a "pushing force". Left ventricular outflow obstruction is considered to be formed by the protruding distal mitral valve and the hypertrophied septum.

Adolescent↗
PubMed1976

Localization of left ventricular outflow obstruction by cross-sectional echocardiography.

Cross-sectional echocardiographic studies were performed using a high resolution real time mechanical sector scanner in 70 patients with left ventricular outflow obstruction. Seven separate obstructive patterns were recorded in these patients. An area of aortic narrowing just distal to the aortic valve at the superior border of the left atrium was noted with supravalvular aortic stenosis. With congenital valvular aortic stenosis there was an increase in echo production by the thickened aortic leaflets. During systole these prominent leaflet echoes curved inward toward the center of the aortic root reflecting the systolic doming of the valve. With calcific aortic stenosis, the calcification produced an area of dense linear echoes attached in varying degrees to either the anterior or posterior border of the aortic root. At the subvalvular level three obstructive patterns were recorded; with a discrete subvalvular obstructive membrane two linear echoes apparently produced by the inner margins of the obstructing membrane were recorded in the outflow tract. With more extensive fibromuscular narrowing of the subvalvular area, there was inward bowing of the echoes from both the anterior and posterior walls of the outflow tract. In one case this was a dense shelf-like mass of echoes extending downward from the basal portion of the interventricular septum toward the mid-portion of the anterior mitral leaflet with corresponding systolic anterior motion of the mitral leaflet. In patients with idiopathic hypertrophic subaortic stenosis there was systolic anterior motion of the anterior mitral leaflet beginning just distal to the point of coaptation of the mitral leaflets and extending distally toward the papillary muscles. This report suggests that the enlarged field of vision and spatial orientation provided by the cross-sectional echocardiographic technic should improve our ability to record and characterize areas of obstruction to left ventricular outflow.

Aortic Stenosis, Subvalvular↗
PubMed1990

Sudden development of intraoperative left ventricular outflow obstruction: differential and mechanism. An intraoperative two-dimensional echocardiographic study.

Systolic anterior motion (SAM) of the mitral valve, once considered to be pathognomonic of hypertrophic cardiomyopathy, has been reported in the absence of asymmetric septal hypertrophy. Of the 1,000 open heart operations performed with intraoperative two-dimensional epicardial echocardiography monitoring, four patients developed intraoperative dynamic left ventricular outflow obstruction associated with systolic anterior motion of the mitral valve that was not present preoperatively: three cases of mitral valve annuloplasty with Carpentier ring insertion and one of coronary artery bypass grafting. Though no patient had asymmetric septal hypertrophy or echocardiographic evidence of outflow obstruction by either preoperative cardiac catheterization or echocardiography, intraoperative two-dimensional epicardial echocardiography revealed SAM, and hyperdynamic left ventricles with three of these patients having documented left ventricular outflow tract gradients causing hemodynamic compromise. (Case 4 was hemodynamically stable following mitral valve repair, but had SAM and significant residual mitral regurgitation [MR] requiring reinstitution of cardiopulmonary bypass and re-repair). Measurement of mitral annular dimension demonstrated a normal decrease in size from diastole to systole in control operative subjects but not in the patients who developed outflow obstruction. The pathophysiology, treatment, and role of intraoperative echocardiography of dynamic left ventricular outflow tract obstruction are discussed.

Aged↗
PubMed1996

Resting echocardiographic features of latent left ventricular outflow obstruction in hypertrophic cardiomyopathy.

We determined resting echocardiographic features predictive of latent left ventricular (LV) outflow obstruction in 50 consecutive patients with nonobstructive hypertrophic cardiomyopathy (26 provocable, 24 nonprovocable with amyl nitrite inhalation) to have a better understanding of the pathophysiology of this condition and to identify such patients without pharmacologic provocation. Measurements included wall thickness, type of hypertrophy, LV outflow tract diameter, degree of mitral systolic anterior motion, outflow pressure gradient, and ventricular volume. The direction of the ejection streamline was measured to assess the magnitude of the drag force acting on the mitral valve. Thirteen of 16 patients (81%) with proximal septal bulge were provocable, whereas only 3 of 8 patients (38%) with asymmetric septal hypertrophy and 10 of 26 (38%) with concentric hypertrophy were provocable (p < 0.05). LV outflow tract was significantly narrower and the angle between the ejection flow and the mitral valve was larger in provocable patients. The sensitivity for predicting provocable patients by a combination of a narrow outflow tract (< or = 2 cm) and a large angle (> or = 35 degrees) was 65%, with a specificity of 80% and a positive predictive value of 79%. When these criteria were combined with the presence of septal bulge, the sensitivity was 35%, but the specificity and the positive predictive value were both 100%. Patients with nonobstructive hypertrophic cardiomyopathy with proximal septal bulge, a narrow LV outflow tract, and an oblique angle between the ejection flow and the mitral valve appeared to be predisposed for latent outflow obstruction. These features are consistent with the presence of the large Venturi and drag forces. Thus, the left ventricle, which is capable of increasing both the Venturi and the drog forces on the basis of the morphologic change, contributes to the development of outflow obstruction with amyl nitrite inhalation.

Cardiomyopathy, Hypertrophic↗
PubMed2003

Unruptured aneurysm of the sinus of Valsalva presenting with right ventricular outflow obstruction.

Sinus of Valsalva aneurysms rarely present until rupture occurs. We describe the case of a patient who presented with acute right heart failure and upon investigation was found to have an unruptured sinus of Valsalva aneurysm causing right ventricular outflow obstruction; there was an associated subaortic ventricular septal defect. To the best of our knowledge, only 1 other case with these features has been reported in the medical literature. The diagnosis was made by transthoracic echocardiography and cardiac catheterization. Through an aortic and right ventricular approach, we successfully excised the aneurysmal right coronary sinus, closed the ventricular septal defect, and replaced the aortic valve.

Adult↗
PubMed1996

Stroke normalized pressure: a useful parameter for the analysis of left ventricular outflow obstruction.

A new method of presenting the in vivo left ventricular pressure-flow data is developed in the present study. This separates left ventricle ejection into unrestricted, progressively restricted and severely restricted cases. This method uses ejection volume and time to define a normalizing 'stroke' pressure, which is successful in collapsing the large variability of in vivo data to a few curves with characteristic shapes, depending on the degree of obstruction. Hypertrophic cardiomyopathy is shown to fall into both unrestricted and progressively restricted categories. Normal hearts form the unrestricted case, while a severe aortic valvular stenosis is characteristic of the severely restricted case.

Aortic Valve Stenosis↗
PubMed1991

The pulmonary artery lasso: epicardial pacing lead causing right ventricular outflow obstruction.

Permanent pacing in small children may require placement of an epicardial pacing system. This report describes a young child who underwent pacemaker implantation with epicardial ventricular lead placement in infancy as an adjunct to antiarrhythmic therapy for congenital junctional ectopic tachycardia. At 5 years of age, a harsh systolic murmur was detected for the first time. Evaluation by catheterization and transluminal echocardiography showed right ventricular outflow obstruction (pressure gradient 40 mmHg) secondary to extrinsic compression by the epicardial lead. Surgical removal of the lead relieved the obstruction.

Cardiac Pacing, Artificial↗
PubMed2001

Echocardiographic correlates of left ventricular outflow obstruction and systolic anterior motion following mitral valve repair.

BACKGROUND AND AIM OF THE STUDY: Systolic anterior motion (SAM) of the mitral valve resulting in left ventricular outflow obstruction is a well-recognized complication of repair of the degenerative myxomatous mitral valve. A precise mechanism is unknown. A current approach consists of sliding annuloplasty of the posterior leaflet. It was postulated that excess tissue of the anterior mitral leaflet (AML) was as equally (or more) important as the excess posterior mitral leaflet (PML) tissue in the development of SAM subsequent to valve repair. METHODS: Thirty-two patients without post-repair SAM (No-SAM group) were compared with eight patients with SAM (SAM group). The AML and PML heights and the mitral annulus diameter were measured by TEE using mid-esophageal four-chamber and long-axis planes. RESULTS: Pre-repair TEE showed the AML height to be greater in the SAM group (p = 0.04), and that of the posterior leaflet tended to be greater (p = 0.08), whilst the annular dimensions were similar in both groups. In the post-repair status, the AML height was markedly greater (p = 0.005) and the annulus markedly smaller (p = 0.001) in the SAM group. Post-repair assessment showed the relative difference between AML height and annular dimension (AML - Ann) as well as the difference between combined leaflet heights and annular dimension (AML + PML - Ann) to be strikingly greater in the SAM group as compared with the No-SAM group (p = 0.001). CONCLUSION: A disparity between dimension of the annulus following mitral valve repair and combined heights of the two leaflets explains post-repair SAM. The AML height is a more important factor in the development of SAM. Thus, surgical techniques to reduce AML heights should be considered in patients with disproportionately large anterior leaflets in order to prevent SAM. Selection of size of the annuloplasty ring should take into consideration the height of the AML.

Echocardiography, Transesophageal↗
PubMed1978

APICAL LEFT VENTRICULAR-ABDOMINAL AORTIC COMPOSITE CONDUITS FOR LEFT VENTRICULAR OUTFLOW OBSTRUCTIONS.

Certain problems related to the left ventricular outflow tract are not amenable to conventional surgical methods, but may be solved with the creation of a double outlet left ventricle by using a composite rigid pyrolite left ventricular apex outlet prosthesis and a fabric valve-containing conduit. Low porosity woven Dacron tube grafts are used for the conduit. Twenty-three patients who have undergone apico-aortic bypass with this conduit are reported here, with gratifying results in eighteen.

Journal Article↗