Transient mid-ventricular obstruction in left ventricle induced by acute pulmonary thromboembolism

Excerpt

A 66-year-old male was admitted to our hospital with acute pulmonary thromboembolism (APTE) and consequent cardiogenic shock. He had a medical history of two incidences of APTE and had been treated with an anticoagulant agent. On admission, his blood pressure was 80/60 mmHg, his heart rate 90 beats/min, his oxygen saturation 90%. A systolic ejection murmur in addition to an accelerated II sound was auscultated. The echocardiogram showed not only high RV systolic pressure but also a mid-ventricular obstruction in the left ventricle (LV), with a 51 mmHg of max pressure gradient (Fig. 1a, b; Movie 1). Because shock progressed rapidly, he was intubated and underwent cardiac catheterization. The simultaneous pressure of the LV-apex and LV-outflow revealed 62 mmHg of pressure gradient in the LV (Fig. 1c). A large amount of thrombus in the pulmonary arteries was identified via pulmonary angiogram. Therefore, an emergent pulmonary arterial thrombectomy was performed, and a very large thrombus was resected from the bilateral pulmonary arteries (Fig. 1d). Thereafter, the LV obstruction disappeared (Fig. 1e; Movie 2) and the patient recovered from shock. A dobutamine-stress cardiac catheterization performed 18 days after surgery did not induce an LV obstruction. The histology findings of the RV septum obtained by myocardial biopsy also were incompatible with hypertrophic cardiomyopathy such as myocyte disarray with an irregular arrangement of abnormal-shaped myocytes (Fig. 1f). This was the patient’s third incidence of APTE, so a permanent filter device was placed in the inferior vena cava.

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