hypotension and valvular dysfunction: chicken or the egg?

6 Dec

CASE PARTICULARS:

–SOB, hypotension

–labs notable for slightly elevated troponin, AKI

DIAGNOSTICS:

–could not undergo CTPA to r/o PE due to AKI
–ECHO in ED shows no RV dilation but did show severe MR and TR.
–pt intubated secondary to massive fluid resuscitation

–ECHO following day was normal. 
–Once rehydrated, pt did much better.  No PE was found on CTPA.

WHAT HAPPENED?
–hypovolemia exacerbated systolic anterior motion of mitral valve causing severe dynamic MR and TR, causing cardiogenic shock. 

TEACHING POINTS:
–This patient had LV outflow tract obstruction by a hyperdynamic anterior motion of the mitral valve leaflets during systole, causing a severe mitral regurgitation due to the blockage of the outflow tract as well as opening of the mitral valve during systole. 

–This mimics HOCM, but was in a structurally normal heart. 
–Obstructive physiology, and especially systolic anterior motion of the mitral valve, can be caused by various disorders including hypercontractile states such as hypovolemia, anemia, beta agonist drugs, D-transposition of the great arteries, congenital/acquired abnormalities of the mitral valve/papillary muscles, and immediately after aortic valve surgery for aortic stenosis (due to acute afterload reduction).

10-SECOND TAKEAWAY:
–suspect massive PE, can’t to CTPA, think of bedside echo to look for RV dilation/strain
–severe hypercontractile states (e.g. hypovolemia) can result in obstructive physiology, including valvular dysfunction
–can be transient, should improve with fluids (good idea for treatment)


Submitted by T. Boyd.

Refence(s): Rosen B et al. “Hypovolemia-Induced Reversible Severe Mitral Regurgitation Due to Left Ventricular Outflow Tract Obstruction.” Echocardiography. 19:8; Nov. 2002.

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