Thread by @EvelynSongMD

1/ #CNCR on a speedboat on Lake Travis!! 😎😁😀

Here's another amazing case with @cardionerds and @prkothapalli @doctormontano @doctormikemg from @DellMedCardio

Catch up on the episode here: cardionerds.com/55-suicide-lv-…

2/ 71yoF w/ h/o CAD s/p PCI to LAD/RCA, pAF s/p ablation, HTN, TIA, and severe symptomatic AS was admitted for elective TAVR.

What's the definition for severe AS on TTE?

#TBT @cardionerds ep. 1&2 on severe AS.
cardionerds.com/episodes/aorti…
@heatherkaganmd @sneha_vk @RaniKHasan

3/ That's right! Severe AS = a mean gradient >40mmHg, a peak velocity >4m/s, and an aortic valve area <1cm2 on TTE.

An increasingly common tx option includes TAVR

What are some feared complications post-TAVR?

4/ The BIG FIVE complications include:

1⃣Moderate/severe PVL
2⃣Vascular & bleeding complications
3⃣Disabling stroke
4⃣AKI
5⃣conduction abnormalities w/ possible need for PPM.

‼️ Pearls:
☑️Larger valves a/w ⬆️blocks
☑️Smaller valves a/w ⬆️ PVL.

5/ Did you know that the term “Big 5” was coined by big-game hunters in Africa and refers to the 5 most-feared animals that are dangerous to encounter on foot? I sure didn't 🤓🤓
🐘🐆🦁🦏🐃

6/ Back to our pt ⏩ she underwent TAVR but became hypotensive while receiving Protamine and PEA arrested requiring CPR

Treated for Protamine rxn w/ steroids & epi but still hypotensive on 3 pressors.

What should be considered on the Ddx for hypotension post-TAVR?

7/ Ddx is broad. Key things to rule out include:

✅Angiogram to r/o MI, dissection, access site complications and bleeding
✅TEE to assess PVL and annular rupture, tamponade
✅ Look for high degree AVB on EKG

⏬⏬ case of shock post-TAVR 2/2 MI

acc.org/education-and-…

8/ For our pt, bedside TTE showed hyperdynamic LV with EF 70%, near-complete mid-distal cavity obliteration

Diagnosed with SUICIDE LV ‼️😲

Check out the TTE of our patient ⏬⏬

9/ The term Suicide LV was first described in 2010 by Dr. Suh et al. @willsuh76 @cwitzke29
pubmed.ncbi.nlm.nih.gov/20506145/

Pathophys:
Chronic severe AS ➡️ LV hypertrophy ➡️ LV wall ⏫thickness ➡️ AS is fixed ➡️ abnormal flow dynamic is unmasked

10/ Management of Suicide LV is similar to that of HOCM:

⬆️preload with IVF
⬆️afterload – phenylephrine is the pressor of choice
🚫inotropes and consider treating with neg inotropes such as BB/CCB
☑️Maintain AV synchrony to maintain adequate LV preload

11/ Listen to the episode to find out what happened to our pt.

Thanks again to @DellMedCardio for a great case! Until next time! #CNCR @cardionerds @karanpdesai