Coincidence of Events Causing Paradoxical Hypotension in a Patient with an Intra-Aortic Balloon Pump
  • Muhammad Atif Masood Noori
    RWJ Barnabas Health/Trinitas Regional Medical Center, Elizabeth, NJ, USA
  • Hardik Fichadiya
    RWJ Barnabas Health/Trinitas Regional Medical Center, Elizabeth, NJ, USA
  • Hasham Saeed
    RWJ Barnabas Health/Trinitas Regional Medical Center, Elizabeth, NJ, USA
  • Qirat Jawed
    RWJ Barnabas Health/Trinitas Regional Medical Center, Elizabeth, NJ, USA
  • Shruti Jesani
    RWJ Barnabas Health/Trinitas Regional Medical Center, Elizabeth, NJ, USA
  • Asnia Latif
    RWJ Barnabas Health/Trinitas Regional Medical Center, Elizabeth, NJ, USA
  • Meherwan Joshi
    RWJ Barnabas Health/Trinitas Regional Medical Center, Elizabeth, NJ, USA

Keywords

IABP, LVOTO, HOCM physiology, SAM, cardiogenic shock

Abstract

The left ventricular outflow tract is a region of the left ventricle that lies between the anterior leaflet of the mitral valve and the ventricular septum. Dynamic left ventricular outflow tract obstruction (LVOTO) has classically been observed in patients with hypertrophic obstructive cardiomyopathy (HOCM) where it occurs secondary to asymmetric septal hypertrophy and systolic anterior motion (SAM) of the mitral valve. However, there are some instances that lead to hypercontractility of the myocardium, and with a combination of other physiological conditions, result in SAM of a mitral valve leaflet, leading to LVOTO in the absence of phenotype.<br/>
We present such a case of an acute inferolateral wall myocardial infarction that was complicated by cardiogenic shock, requiring an intra-aortic balloon pump (IABP) and inotropic support which paradoxically provoked LVOTO. A reduction in IABP counterpulsation from 1:1 to 1:3 and the addition of intravenous fluids and a beta blocker resulted in significant improvement in blood pressure with rapid tapering of pressors.
Inotropes and IABP, although helpful in cardiogenic shock, have the potential to induce or worsen the LVOTO, which can lead to a vicious cycle of worsening hypotension and increasing adrenergic drive that further deteriorates myocardial viability. Timely diagnosis with an echocardiogram and the withdrawal of inotropic and IABP support has the potential to improve haemodynamics and, thereby, outcome.

VIEW THE ENTIRE ARTICLE

References

  • Wigle ED, Rakowski H, Kimball BP, Williams WG. Hypertrophic cardiomyopathy: clinical spectrum and treatment. Circulation 1995 Oct 1;92(7):1680–1692.
  • Di Vece D, Silverio A, Bellino M, Galasso G, Vecchione C, LaCanna G, et al. Dynamic left intraventricular obstruction phenotype in Takotsubo syndrome. J Clin Med 2021 Jan;10(15):3235.
  • Chockalingam A, Dorairajan S, Bhalla M, Dellsperger KC. Unexplained hypotension: the spectrum of dynamic left ventricular outflow tract obstruction in critical care settings. Crit Care Med 2009 Feb 1;37(2):729–734.
  • Haley JH, Sinak LJ, Tajik AJ, Ommen SR, Oh JK. Dynamic left ventricular outflow tract obstruction in acute coronary syndromes: an important cause of new systolic murmur and cardiogenic shock. Mayo Clin Proc 1999 Sep;74(9):901–906. doi: 10.4065/74.9.901
  • Kern MJ, Aguirre F, Bach R, Donohue T, Siegel R, Segal J. Augmentation of coronary blood flow by intra-aortic balloon pumping in patients after coronary angioplasty. Circulation1993 Feb;87(2):500–511. doi: 10.1161/01.cir.87.2.500
  • Cohen R, Rivagorda J, Elhadad S. Asymmetric septal hypertrophy complicated by dynamic left ventricular obstruction after intra-aortic balloon counterpulsation placement in the setting of anterior myocardial infarction. J Invasive Cardiol 2006 Jul 1;18(7):E207–208.
  • Chockalingam A, Dellsperger KC. Isolated dynamic left ventricular outflow tract obstruction can cause hypotension that rapidly responds to intravenous beta blockade. Am J Ther 2011 Sep 1;18(5):e172–176. doi: 10.1097/MJT.0b013e3181cea0dd
  • Chockalingam A, Tejwani L, Aggarwal K, Dellsperger KC. Dynamic left ventricular outflow tract obstruction in acute myocardial infarction with shock: cause, effect, and coincidence. Circulation 2007 Jul 31;116(5):e110–113. doi: 10.1161/CIRCULATIONAHA.107.71169
  • Views: 944
    HTML downloads: 79
    PDF downloads: 336


    Published: 2022-05-02
    Issue: 2022: Vol 9 No 5 (view)


    How to cite:
    1.
    Noori MAM, Fichadiya H, Saeed H, Jawed Q, Jesani S, Latif A, Joshi M. Coincidence of Events Causing Paradoxical Hypotension in a Patient with an Intra-Aortic Balloon Pump. EJCRIM 2022;9 doi:10.12890/2022_003341.

    Most read articles by the same author(s)