Left Ventricular Outflow Tract Obstruction (LVOTO)

OVERVIEW

  • associated with myocardial hypertrophy and systolic anterior motion of the the mitral vale
  • important to recognise as can contribute to a low output state that gets worse with inotropic support

ASSESSMENT

History

  • hypertension
  • post AVR
  • known LVH or HCM
  • increasing inotropes
  • no tamponade

Examination

  • late systolic murmur over the praecordium

Investigations

  • ECHO:
    • -> small LV cavity
    • -> normal systolic function and no RWMA
    • -> AVR functioning well
    • -> flow acceleration noted in LVOT on colour Doppler
    • -> reduced LVOT area during systole
    • -> systolic anterior motion of valve leaflets (MR)
    • -> high peak gradient across LVOT

MANAGEMENT

  • stop adrenaline
  • volume load
  • beta-blockers to slow heart rate and reduce contractility
  • calcium antagonist
  • AV sequential pacing
  • vasoconstrictor without inotropic effect (ie. phenylephrine/noradrenaline)
  • myomectomy or resection of outflow tract

References and Links

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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