Thread by @dr_benoy_n_shah

**VALVE CASE OF THE WEEK**

Old case from 2010...but you know what they say...old is gold! 😁

Female, mid 70s, inter-hospital transfer for urgent angiography due to chest tightness with ischaemic ECG. CP came on 12hrs after distressing news of sudden family death. ECG 👇🏽

Exam - loud systolic murmur, so urgent TTE requested before angio. Here is PLAX. Apologies no ECG, cables on portable Vivid-i were broken!

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PLAX Zoom...

M-mode of mitral valve. No ECG, red arrows indicate systole!

Colour in PLAX view...

AP4Ch...

AP4Ch with zoom on mitral valve...

AP5Ch with colour Doppler...

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CW Doppler through AV...

So...what's going on here?! How are we going to manage this? Is this ACS in someone with previously undetected HOCM? Is this transient LVOTO due to hypovolaemia? Is this Takotsubo, given CP after distressing phone call? Is this severe aortic stenosis & ECG shows strain? Vote! 👇🏽

What explains these images best?

Answer tomorrow!

#echofirst #cardiotwitter #MedTwitter #eacvi #ACCFIT

So, poll closed! Most votes for Takotsubo - which was indeed this lady's diagnosis - but almost 1/5 votes were for an alternative answer so let's go through this...

Why isn't this severe AS? Firstly, look at the PLAX view again... you can see AV leaflets not heavily calcified or restricted. If you watch closely, they do open quite well.

Secondly, look at shape of CW Doppler signal - AS usually has an early systolic peak if mild or moderate which then often becomes mid-systolic in severe AS. Late systolic peak is not typical of AS and usually seen in dynamic outflow tract obstruction...👇🏽

Why not hypovolaemia? Well there wasn't really anything in the history to indicate hypovolaemia and LV isn't particularly underfilled...

So that leaves ACS in a HOCM patient vs Takotsubo syndrome with reversible LVOTO. To be fair one could make an argument for both, but...

Here is Left coronary artery...

And again...

Here is Right coronary artery...

And here is the ventriculogram...

Here is a still of the LV cine...

So, we diagnosed Takotsubo syndrome with associated SAM and LVOTO. She did have a CMR which showed no infarct pattern of LGE and findings consistent with TS

Brought her back few weeks later for repeat TTE...

Here is AP4Ch now...

No more SAM...!

Here is repeat CW Doppler now across AV...

Turbulence had disappeared on colour Doppler

LV back to normal...

It was from this case a decade ago that I learnt that in up to 10% cases, Takotsubo syndrome can be complicated by SAM of AMVL with LVOTO. Important to know this as some patients with TS can be hypotensive and, if LVOTO present, vasopressors will make things worse, not better

In fact we wrote this up as an 'Echo Rounds' in Echocardiography as back then I don't think there was as much awareness of this phenomenon as there is now.

Anyway, new case next week! 😁