Cath Conference

A 73 Year Old Woman with Chest Pain on Christmas Eve

Prepared by Michael Ragosta, MD

Professor of Medicine

University of Virginia Health System

On the afternoon of Christmas Eve, a 73 year old,

basically healthy woman with HTN and asthma was at

yoga class when she developed nausea and a “sick”

feeling.

She sat in the locker room by herself to see if it would

pass, but it continued for an hour and then she

developed chest pressure so decided to call for some

help.

The ambulance arrived at the yoga class and found her

diaphoretic, clutching her chest with a systolic blood

pressure of 65 mmHg.

She is taken to the ER. The ER physician examines her and thinks he hears a murmur. The following ECG is obtained:

The ER physician calls the Cardiologist on call.

What would you do now?

a. Administer lytic therapy

b. Get an echocardiogram

c. Call in the cath lab

d. Have another egg nog since its Christmas Eve

Given IV heparin and aspirin.

Brought to cath lab emergently.

The following set of angiograms are obtained.

LCA angiogram = 1.avi

Video of Left Coronary Artery

What would you do now?

a. Stop the procedure and admit her to the Hospitalist service for further management.

b. Stent something, preferably in the LAD

c. Perform left ventriculography

LV gram = lv.avi

Left Ventriculogram

Following the LV gram, the operator observed a pressure gradient across the aortic valve during the pull back from the LV to the AO.

Notice anything unusual about the aortic waveform?

What would you do now?

a. Call a surgeon for emergent mitral valve surgery

b. Measure simultaneous LV – AO pressure with a dual lumen pigtail catheter.

c. Perform a right heart catheterization

d. Flush the catheter and reassess

Simultaneous LV-AO pressurePigtail mid cavity position

Simultaneous LV-AO pressurePigtail just below aortic valve

What is the most likely diagnosis?

a. Severe aortic stenosis with acute mitral regurgitation

b. Acute anterior MI from vasospasm that has resolved.

c. Acute myocarditis with aortic stenosis

d. Takotsubo cardiomyopathy with outflow obstruction

e. Hypertrophic obstructive cardiomyopathy

Echocardiogram

Echocardiogram

Hospital Course

• Chest pain resolved in a few hours.

• Troponin peaked at 13.18 ng/dL.

• Persistently hypotensive for several days requiring phenylephrine. Slowly improved and pressors weaned.

• MRI obtained: no delayed enhancement but edema of the apex. Prominent basal portion of the anteroseptum measuring 13 mm thick.

One Month Follow-Up

• No further chest pain and feeling well.

• Wants to exercise again.

• Follow-up echocardiogram obtained.

Echocardiogram at One Month

Echocardiogram at One Month

Discussion Points

• Consider “acquired” outflow track obstruction as a cause of hypotension or shock.

• Not uncommon in takotsubo cardiomyopathy: up to 25% of patients (Am Heart J 2008;156:543-8).

• Outflow tract obstruction may also be seen after large anterior MI from distortion of ventricular anatomy and hyperkinesis of the bases leading to SAM.

• If unrecognized, some pressors chosen to treat hypotension might make it worse.