2. CASE VIGNETTE
• 60 yr/f
• DM / HTN / CAD / LVH
• Fever 3 days
• Burning micturition 2 days,
IN ER :
• HR : 130
• BP : 80 / 40
• TEMP : 102F
• Conscious , oriented
• SPO2 : 98% ON RA
FLUID RESUSCITATION – 30 ml/kg
VASOPRESSORS
desaturates and develops crepts
WORSENING HYPOTENSION
LVOTO
3. HCM AND LVOTO
Apical hypertrophy
Symmetrical hypertrophy
Asymmetrical septal hypertrophy without obstruction
Asymmetrical septal hypertrophy with obstruction
Inc LV wall thickness at least 15 mm in one/
more LV myocardial segments
instantaneous peak Doppler LVOT pressure gradient at least
30 mmHg at rest or during physiological provocation
5. PATHOPHYSIOLOGY
Decrease preload Decrease afterload
Increase heart rate Increase contractility
Small and
hypercontractile
LV
Needs two factors :
• Anatomical substrate
• Physiological predisposing
conditions
6. Stress cardiomyopathy –
takatsubocardiomyopathy
hypercontractile LV base
mid and distal akinesia
reduction in LV chamber size
bleeding, diuretics, trauma, or inotrope infusion
crowding at the LV outflow level
results in systolic anterior motion of the mitral apparatus
dynamic obstruction
Hypotension
new prominent systolic ejection
murmur in the left third
parasternal area
7. DIAGNOSIS
• new systolic murmur in the left low sternal border that increases with Valsalva maneuver or
postextrasystole
• Definitive diagnosis requires performing an echocardiogram as soon as possible
8. TREATMENT
Increase preload Increase afterload
Decrease heart rate Decrease contractility
Stop
Diuretics
Vasopressors
Ionotropic agents
Nitrates
Start
IV fluids
B blockers
Ca chnl blockers
Disopyramide
11. IMPORTANCE
IVO occurrence in septic shock patients;
correlation between the intraventricular gradient and volume status and fluid responsiveness;
mortality rate.
prospectively analyzed 218 patients ,septic shock admitted to a general ICU over a 28-month
12. CASE VIGNETTE
• 60 yr/f
• DM / HTN / CAD / LVH
• Fever 3 days
• Burning micturition 2 days,
IN ER :
• HR : 130
• BP : 80 / 40
• TEMP : 102F
• Conscious , oriented
• SPO2 : 98% ON RA
FLUID RESUSCITATION – 30 ml/kg
VASOPRESSORS
desaturates and develops crepts
WORSENING HYPOTENSION
LVOTO
13. Take home message
• Identify existence of a phenomena of LVOT obstruction in ICU
• Learn to measure LVOT pressure gradient using doppler
• Early adequate fluid resuscitation of all sepsis patients
• Use of B blockers once hemodynamics are controlled with vasopressors to reduce the heart rate
• Plan a observational study of measuring LVOT pressure gradient in all septic shock patients and
see how it progresses with treatment and how it influences mortality
14. EYES WILL SEE ONLY WHAT THE MIND KNOWS…….
THANK YOU……