Diverse geometric changes related to dynamic left ventricular outflow tract obstruction without overt hypertrophic cardiomyopathy

Abstract

Background: Dynamic left ventricular (LV) outflow tract (LVOT) obstruction (DLVOTO) is not infrequently observed in older individuals without overt hypertrophic cardiomyopathy (HCM). We sought to investigate associated geometric changes and then evaluate their clinical characteristics.

Methods: A total of 168 patients with DLVOTO, which was defined as a trans-LVOT peak pressure gradient (PG) higher than 30 mmHg at rest or provoked by Valsalva maneuver (latent LVOTO) without fixed stenosis, were studied. Patients with classical HCM, acute myocardial infarction, stress induced cardiomyopathy or unstable hemodynamics which potentially induce transient-DLVOTO were excluded.

Results: Their mean age was 71 ± 11 years and 98 (58%) patients were women. Patients were classified as pure sigmoid septum (n = 14) if they have basal septal bulging but diastolic thickness less than 15 mm, sigmoid septum with basal septal hypertrophy for a thickness ≥15 mm (n = 85), prominent papillary muscle (PM) (n = 20) defined by visually large PMs which occluded the LV cavity during systole or 1/2 LVESD, or as having a small LV cavity with concentric remodelling or hypertrophy (n = 49). The prominent PM group was younger, had a higher S' and lower E/e' than other groups. In all groups, a higher peak trans-LVOT PG was related (p < 0.10) to higher E/e', systolic blood pressure, relative wall thickness, and pulmonary arterial systolic pressure. In multivariate analysis, resting trans-LVOT PG correlated to pulmonary arterial pressure (ß = 0.226, p = 0.019) after adjustment for systolic blood pressure, relative wall thickness, and E/e'.

Conclusions: DLVOTO develops from various reasons, and patients with prominent PMs have distinct characteristics. We suggest to use DLVOTO-relieving medication might reduce pulmonary pressure in this group of patients.

Figure 1

Representative cases of DLVOTO with Doppler patterns at rest and during Valsalva maneuver. A case with leaflet systolic anterior motion (SAM) (A), a case with chordal SAM (B), and a case with prominent papillary muscles kissing to septum (C).

Figure 2

Assessment of geometry-associated left ventricular outflow tract obstruction. Measurements of basal septal wall thickness at end-diastole, the angle between the ascending aorta and the plane of the mitral valvular orifice at both end-diastole (A) and end-systole (B) from 3-chamber view images.

Figure 3

Representative case for each subgroup. Pure sigmoid septum (A), sigmoid septum with basal septal hypertrophy (B), prominent papillary muscle (C) and small LV cavity due to concentric remodelling (D).