Abstract
Dynamic left ventricular outflow tract obstruction (DLVOTO) or midcavity obstruction in patients with structurally normal hearts is not uncommon in routine clinical practice and can cause significant symptoms mimicking coronary artery disease or heart failure. Although exercise echocardiography is the gold standard for assessing DLVOTO, dobutamine stress echocardiography (DSE) may be valuable diagnostic modality in patients who are unable to exercise or have an uninterpretable 12-lead electrocardiogram. We provide an updated overview of the relevant literature regarding prevalence, pathophysiology, clinical significance, and prognostic impact of DLVOTO and midcavity obstruction in structurally normal hearts. We also present a clinical series of 4 cases of DLVOTO and midcavity obstruction documented by DSE and discuss the value of different kinds of modern stress imaging modalities involving: (1) contrast-enhanced DSE to assess myocardial perfusion and inducible ischemia; (2) adenosine stress echocardiography to assess coronary flow reserve/microvascular dysfunction; and (3) functional imaging with deformation echocardiography to assess subclinical myocardial dysfunction in patients with structurally normal heart and without significant coronary disease. Based upon our own experiences and a critical review of the current literature, we will then present a practical guidance for management of DLVOTO and midcavity obstruction.
References
1.
Maron
MS
, Olivotto
I
, Zenovich
AG
, Link
MS
, Pandian
NG
, Kuvin
JT
, et al. Hypertrophic cardiomyopathy is predominantly a disease of left ventricular outflow tract obstruction
. Circulation
. 2006
;114
(114
):2232
–9
. .2.
Liu
S
, Baribeau
Y
, Ahmed
A
, Sharkey
A
, Chu
L
, Mahmood
F
, et al. Dynamic left ventricular outflow tract obstruction in the setting of acute myocardial infarction
. J Cardiothorac Vasc Anesth
. 2019
;33
(33
):3423
–6
. .3.
Webster
KT
, Apridonidze
T
, Mopala
PR
, Sherman
AE
, Potakamuri
LN
, Storms
DR
, et al. Stress-induced cardiomyopathy complicated by dynamic left ventricular outflow obstruction, cardiogenic shock, and ventricular septal rupture
. Can J Cardiol
. 2019
;35
(35
):229.e7
-e9
. .4.
Fazal
AA
, Patoli
DM
, Asher
SR
. The perfect storm: dynamic left ventricular outflow tract obstruction and the use of point of care cardiac ultrasound to guide intraoperative management
. J Clin Anesth
. 2019
;57
(57
):75
–6
. .5.
Slama
M
, Tribouilloy
C
, Maizel
J
. Left ventricular outflow tract obstruction in ICU patients
. Curr Opin Crit Care
. 2016
;22
(3
):260
–6
. .6.
Pelikka
PA
, Oh
JK
, Bailey
KR
, Nichols
BA
, Monahan
KH
, Tajik
AJ
. Dynamic intraventricular obstruction during dobutamine stress echocardiography: a new observation
. Circulation
. 1992
;86
:1429
–32
.7.
Voci
P
, Pizzuto
F
, Romeo
F
. Coronary flow: a new asset for the echo lab?
Eur Heart J
. 2004
;25
(21
):1867
–79
. .8.
Harrison
MR
, Grigsby
CG
, Souther
SK
, Smith
MD
, DeMaria
AN
. Midventricular obstruction associated with chronic systemic hypertension and severe left ventricular hypertrophy
. Am J Cardiol
. 1991
;68
(8
):761
–5
. .9.
Cotrim
C
, Almeida
AG
, Carrageta
M
. Exercise-induced intra-ventricular gradients as a frequent potential cause of myocardial ischemia in cardiac syndrome X patients
. Cardiovasc Ultrasound
. 2008
;6
(6
):3
. .10.
Zywica
K
, Jenni
R
, Pellikka
PA
, Faeh-Gunz
A
, Seifert
B
, Attenhofer Jost
CH
. Dynamic left ventricular outflow tract obstruction evoked by exercise echocardiography: prevalence and predictive factors in a prospective study
. Eur J Echocardiogr
. 2008
;9
(5
):665
–71
. .11.
Cabrera-Bueno
F
, Gómez-Doblas
JJ
, Muñoz-García
A
, García-Pinilla
JM
, Navarro
MJ
, de Teresa-Galván
E
. Effort angina, normal coronary angiogram, and dynamic left ventricular obstruction
. J Am Soc Echocardiogr
. 2007
;20
(4
):415
–20
. .12.
Cabrera-Bueno
F
, Rodriguez Bailon
I
, Lopez Salguero
R
, Gómez Doblas
JJ
, Pérez Cabeza
A
, Peña Hernández
J
, et al. Dynamic left ventricular outflow tract obstruction induced by exercise
. Rev Esp Cardiol
. 2004
;57
:1179
–87
.13.
Cotrim
C
, Lopes
LR
, Almeida
AR
, Miranda
R
, Almeida
AG
, Cotrim
H
, et al. Efficacy of beta-blocker therapy in symptomatic athletes with exercise-induced intra-ventricular gradients
. Cardiovasc Ultrasound
. 2010
;8
(8
):38
. .14.
Peteiro
J
, Montserrat
L
, Castro-Beiras
A
. Labil subaortic obstruction during exercise stress echocardiography
. Am J Cardiol
. 1999
;84
(9
):1119
–1
. .15.
Cotrim
C
, Almeida
AG
, Carrageta
M
. Cardiac syndrome X, intraventricular gradients and, beta-blockers
. Rev Port Cardiol
. 2010
;29
(29
):193
–203
.16.
Luria
D
, Klutstein
MW
, Rosenmann
D
, Shaheen
J
, Sergey
S
, Tzivoni
D
. Prevalence and significance of left ventricular outflow gradient during dobutamine echocardiography
. Eur Heart J
. 1999
;20
(5
):386
–92
. .17.
Lau
TK
, Navarijo
J
, Stainback
R
. Pseudo-false-positive exercise treadmill testing caused by systolic anterior motion of the anterior mitral valve leaflet
. Tex Heart Inst J
. 2001
;28
(4
):308
–11
.18.
Dawn
B
, Paliwal
VS
, Raza
ST
, Mastali
K
, Longaker
RA
, Stoddard
MF
. Left ventricular outflow tract obstruction provoked during dobutamine stress echocardiography predicts future chest pain, syncope, and near syncope
. Am Heart J
. 2005
;149
(5
):908
–16
. .19.
Cabrera-Bueno
F
, García-Pinilla
JM
, Gómez-Doblas
JJ
, Montiel-Trujillo
A
, Rodríguez-Bailón
I
, de Teresa-Galván
E
. Beta-blocker therapy for dynamic left ventricular outflow tract obstruction induced by exercise
. Int J Cardiol
. 2007
;117
(117
):222
–6
. .20.
Al-Nasser
F
, Duncan
A
, Sharma
R
, O’Sullivan
C
, Coats
AJ
, Anker
SD
, et al. Beta-blocker therapy for dynamic left-ventricular outflow tract obstruction
. Int J Cardiol
. 2002
;86
(2–3
):199
–205
. .21.
Barletta
G
, Del Bene
MR
, Gallini
C
, Salvi
S
, Costanzo
E
, Masini
M
, et al. The clinical impact of dynamic intraventricular obstruction during dobutamine stress echocardiography
. Int J Cardiol
. 1999
;70
(2
):179
–89
. .22.
Meimoun
P
, Benali
T
, Sayah
S
, Luycx-Bore
A
, Maitre
B
, Tribouilloy
C
. Significance of systolic anterior motion of the mitral valve during dobutamine stress echocardiography
. J Am Soc Echocardiogr
. 2005
;18
(18
):49
–56
. .23.
Murakami
H
, Nishimura
M
, Urabe
K
. Relation between dynamic midventricular obstruction and unexplained chest pain in patients with normal echocardiograms at rest
. Am J Cardiol
. 1996
;78
(9
):1063
–5
. .24.
Henein
MY
, O’Sullivan
C
, Sutton
GC
, Gibson
DG
, Coats
AJ
. Stress-induced left ventricular outflow tract obstruction: a potential cause of dyspnea in the elderly
. J Am Coll Cardiol
. 1997
;30
(5
):1301
–7
. .25.
Christiaens
L
, Duplantier
C
, Allal
J
, Donal
E
, Nanadoumgar
H
, Barraine
R
, et al. Normal coronary angiogram and dobutamine induced left ventricular obstruction during stress echocardiography: a higher hemodynamic responsiveness to dobutamine
. Echocardiography
. 2001
;18
:285
–90
.26.
Mertes
H
, Erbel
R
, Nixdorff
U
, Mohr-Kahaly
S
, Krüger
S
, Meyer
J
. Exercise echocardiography for the evaluation of patients after nonsurgical coronary artery revascularization
. J Am Coll Cardiol
. 1993
;21
(5
):1087
–93
. .27.
Alhaj
EK
, Kim
B
, Cantales
D
, Uretsky
S
, Chaudhry
FA
, Sherrid
MV
. Symptomatic exercise-induced left ventricular outflow tract obstruction without left ventricular hypertrophy
. J Am Soc Echocardiogr
. 2013
;26
(26
):556
–65
. .28.
Park
SM
, Kim
MN
, Kim
SA
, Kim
YH
, Kim
MG
, Shin
MS
, et al. Clinical significance of dynamic left ventricular outflow tract obstruction during dobutamine stress echocardiography in women with suspected coronary artery disease
. Circ J
. 2015
;79
(79
):2255
–62
. .29.
Hashimoto
Y
, Reid
CL
, Gardin
JM
. Left ventricular cavitary geometry and dynamic intracavitary left ventricular obstruction during dobutamine stress echocardiography
. Am J Card Imaging
. 1996
;10
(3
):163
–9
.30.
Cabrera-Bueno
FJ
, Gómez-Doblas
JJ
, Garcia-Pinilla
JM
, Montiel-Trujillo
A
, Jiménez-Navarro
M
, Martinez-Del-Valle
D
, et al. Dobutamine stress echocardiography identifies patients with angina and dynamic left ventricular outflow obstruction in physiological exercise
. Echocardiography
. 2009
;26
(26
):272
–80
. .31.
Chockalingam
A
, Xie
GY
, Dellsperger
KC
. Echocardiography in stress cardiomyopathy and acute LVOT obstruction
. Int J Cardiovasc Imaging
. 2010
;26
(26
):527
–35
. .32.
Elliott
PM
, Anastasakis
A
, Borger
MA
, Borggrefe
M
, Cecchi
F
, Charron
P
, et al. ESC guidelines on diagnosis and management of hypertrophic cardiomyopathy: the task force for the diagnosis and management of hypertrophic cardiomyopathy of the European Society of Cardiology (ESC)
. Eur Heart J
. 2014
;35
:2733
–79
.33.
Secknus
MA
, Niedermaier
ON
, Lauer
MS
, Marwick
TH
. Diagnostic and prognostic implications of left ventricular cavity obliteration response to dobutamine echocardiography
. Am J Cardiol
. 1998
;81
(81
):1318
–22
. .© 2021 S. Karger AG, Basel
2021
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.
