AN ATYPICAL PRESENTATION OF CONCENTRIC HYPERTROPHIC CARDIOMYOPATHY IDENTIFIED VIA POINT-OF-CARE ULTRASONOGRAPHY

Abstract

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Left ventricular outflow tract obstruction (LVOTO) is not an uncommon finding in ICU patients and can be observed during the early phase of septic shock due to decreased preload, decreased afterload or hyperdynamic left ventricle. It is also a well recognized phenomenon in hypertrophic cardiomyopathy (HOCM) due to systolic anterior motion (SAM) of the anterior mitral leaflet with mitral-septal contact. Here we will discuss a case of HOCM with coexistent severe mitral regurgitation causing dynamic LVOTO presenting as respiratory failure and cardiogenic shock. Early detection of cardiogenic shock due to LVOTO with the use of bedside focused cardiac ultrasonography (FoCUS) in our patient allowed us to optimize pharmacological treatments with plan for corrective surgery within twelve hours of admission. CASE PRESENTATION: A 56 year old male with history of hypertension and coronary artery disease with stent placement was admitted for acute chest pain and shortness of breath with associated chills and productive cough. Acute coronary syndrome was excluded. Early respiratory decompensation, requiring endotracheal intubation, raised concern for bacterial pneumonia with progression towards acute respiratory distress syndrome (ARDS). A FoCUS exam was performed to evaluate for cardiogenic cause, which revealed hypertrophic cardiomyopathy confirmed with calculated measurements of septal hypertrophy (20.5 mm), septal to free wall thickness ratio (1.18) indicating a concentric variant, and a left ventricular outflow gradient (240.6 mmHg) with systolic anterior motion of the anterior mitral leaflet seen on M-mode. Severe mitral regurgitation was also visualized on color doppler. A pulmonary artery catheter was placed for invasive hemodynamic monitoring. He developed second degree atrioventricular block Mobitz type 2 and a transvenous pacer was placed. Medical management was optimized with improvement to his hemodynamics and hypoxia leading to extubation. Electrophysiology placed a dual chamber implantable cardioverter defibrillator, and cardiovascular surgery initiated preoperative work up for outpatient septal myectomy and mitral valve replacement. Septal tissues to later be examined to identified etiology of this late onset process. DISCUSSION: Early recognition and rapid clinical decision making is vital in the critical care setting and advancements in medical technology are allowing for quick intervention to be done with the highest accuracy. The use of point of care ultrasound is becoming more commonplace in emergency and critical care setting as a rapid diagnostic tool. CONCLUSIONS: As seen in this case, without the use of FoCUS, the appropriate diagnosis and management would have been delayed for hours to days increasing the mortality in this individual. Reference #1: Maria-Angela Losi, Stefano Nistri, Maurizio Galderisi, Sandro Betocchi, Franco Cecchi, Iacopo Olivotto, . . . Society of Cardiology. (2010, March 17). Echocardiography in patients with hypertrophic cardiomyopathy: Usefulness of old and new techniques in the diagnosis and pathophysiological assessment. Retrieved from https://cardiovascularultrasound.biomedcentral.com/articles/10.1186/1476-7120-8-7 Reference #2: Sobczyk, D. (2014, December). Dynamic left ventricular outflow tract obstruction: Underestimated cause of hypotension and hemodynamic instability. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4579722/ DISCLOSURES: No relevant relationships by Mindy Bui, source=Web Response No relevant relationships by Michael Girard, source=Web Response No relevant relationships by Daniel Gomez, source=Web Response No relevant relationships by Christopher King, source=Web Response No relevant relationships by Benjamin Phelps, source=Web Response