Case report
ECMO as rescue therapy in TAVI-induced cardiogenic shock: A case of suicide left ventricle
ECMO como terapia de rescate en choque cardiogénico inducido por TAVI: un caso de ventrículo izquierdo suicida
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It is still necessary?" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1148 "Ancho" => 2508 "Tamanyo" => 190883 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ley física de Hagen–Poiseuille esquematizada.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Yasser Colao Jimenez" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Yasser" "apellidos" => "Colao Jimenez" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1134009624000032?idApp=UINPBA00004N" "url" => "/11340096/unassign/S1134009624000032/v1_202403010438/es/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "ECMO as rescue therapy in TAVI-induced cardiogenic shock: A case of suicide left ventricle" "tieneTextoCompleto" => true "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Gustavo Rojas-Velasco, Regina Aguilar-López, Renata Toledo-Elías, Octavio Salazar-Delgado, Natalia Coello-Niembro, María Jiménez-Fernández, Eduardo A. Arias, Daniel Manzur-Sandoval" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Gustavo" "apellidos" => "Rojas-Velasco" "email" => array:1 [ 0 => "gustavorojas08@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Regina" "apellidos" => "Aguilar-López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Renata" "apellidos" => "Toledo-Elías" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Octavio" "apellidos" => "Salazar-Delgado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Natalia" "apellidos" => "Coello-Niembro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "María" "apellidos" => "Jiménez-Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "Eduardo A." "apellidos" => "Arias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 7 => array:3 [ "nombre" => "Daniel" "apellidos" => "Manzur-Sandoval" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "La Salle University, Mexico City, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Interventional Cardiology Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "ECMO como terapia de rescate en choque cardiogénico inducido por TAVI: un caso de ventrículo izquierdo suicida" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1157 "Ancho" => 3167 "Tamanyo" => 335426 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Immediate post-TAVI transthoracic echocardiogram. Continuous wave Doppler showing (A) intraventricular gradient of 23<span class="elsevierStyleHsp" style=""></span>mmHg and maximum velocity of 2.4<span class="elsevierStyleHsp" style=""></span>m/s, no SAM of the mitral valve was documented, (B) LV mid-cavitary gradient. LV<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>left ventricle, TAVI<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>transcatheter aortic valve implantation, SAM<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>systolic anterior motion.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Transcatheter aortic valve implantation (TAVI) is a less invasive technique compared to surgical aortic valve replacement (SAVR), used in patients with severe aortic stenosis, especially in those with a high surgical risk and frailty.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> However, a potentially fatal complication of this procedure has been acknowledged as “suicide left ventricle” (SLV). Although its pathophysiology is still poorly understood, after the relief of the aortic valve stenosis with a subsequent reduction in left ventricular pressures, a dynamic intraventricular obstruction occurs, manifested as severe hemodynamic instability. This phenomenon has been described in both SAVR and TAVI procedures.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Based on the literature, dynamic intraventricular obstruction has been reported in approximately 15% of patients undergoing SAVR.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> However, its exact incidence in TAVI is unknown. A retrospective observational study published by Kaewkes et al. (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1729) found that 1.8% of patients who underwent TAVI had significant left ventricular obstruction features present in the transthoracic echocardiogram (TTE), nevertheless, only one patient developed hemodynamic compromise.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Some risk factors that can contribute to the development of an SLV are female sex, a sigmoid-shaped septum, asymmetric septal hypertrophy, a small ventricular cavity, a normal left ventricular ejection fraction (LVEF), high peri-procedural transvalvular gradients, and a narrow left ventricle outflow tract (LVOT).<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3,4</span></a> In most cases, dynamic intraventricular gradients occur in mid-ventricular locations, especially when there is concentric hypertrophy of the interventricular septum.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">SLV treatment should focus on increasing preload and afterload to improve left ventricle filling pressures and reduce contractility.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Conventional treatment includes volume loading and beta-blockers as the mainstays for this pathology.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> Other options include strategies such as right ventricular pacing, surgical myomectomy, and alcohol septal ablation.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,3,4,6</span></a> Furthermore, for severe and refractory cases, extracorporeal membrane oxygenation (ECMO) therapy has been described.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Text</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 75-year-old male was referred to our institution in consideration for an aortic valve replacement. At the time of admission, he was hemodynamically stable but presented a 12-month history of progressive decline in functional class (New York Heart Association III), syncope, and chest pain. Vital signs showed blood pressure of 150/100<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate of 80<span class="elsevierStyleHsp" style=""></span>beats per minute, a respiratory rate of 14 breaths per minute with oxygen saturation of 92%, and he was afebrile. Physical examination revealed a body mass index of 26.8<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span> (height 1.77<span class="elsevierStyleHsp" style=""></span>m and weight 84<span class="elsevierStyleHsp" style=""></span>kg), jugular venous distension, an ejection systolic murmur in the aortic region radiating to the neck vessels, and lower extremity edema. His past medical history included severe aortic valve stenosis diagnosed 2 years before, dyslipidemia, hypertension, and paroxysmal atrial fibrillation with poor treatment adherence.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The electrocardiogram showed sinus rhythm and left ventricular hypertrophy. Preoperative TTE revealed severe aortic valve stenosis with significant thickening and reduced mobility of the valve leaflets (valve area of 0.62<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>, mean gradient of 58<span class="elsevierStyleHsp" style=""></span>mmHg, maximum 103<span class="elsevierStyleHsp" style=""></span>mmHg, and a peak velocity of 5<span class="elsevierStyleHsp" style=""></span>m/s). In addition, moderate mitral regurgitation and mild tricuspid insufficiency were reported. The left ventricle exhibited a mildly reduced LVEF of 49%, a relatively small cavity (42<span class="elsevierStyleHsp" style=""></span>mm at end-diastole), concentric hypertrophy with a septal thickness of 18<span class="elsevierStyleHsp" style=""></span>mm and a posterior wall thickness of 16<span class="elsevierStyleHsp" style=""></span>mm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). LVOT diameter was 1.59<span class="elsevierStyleHsp" style=""></span>cm, and a peak gradient of 2<span class="elsevierStyleHsp" style=""></span>mmHg was measured. The right ventricle was enlarged and presented reduced ventricular function (TAPSE of 12<span class="elsevierStyleHsp" style=""></span>mm). A pulmonary artery systolic pressure of 72<span class="elsevierStyleHsp" style=""></span>mmHg and a mean of 42<span class="elsevierStyleHsp" style=""></span>mmHg were quantified. CT scan measured an aortic annulus at 23<span class="elsevierStyleHsp" style=""></span>mm, severe calcification (5054.5<span class="elsevierStyleHsp" style=""></span>AU), and revealed a sigmoid septum. A coronary angiogram showed no significant coronary artery disease.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">After evaluating the patient's characteristics, surgical risk, and comorbidities, it was determined that he met the appropriate criteria for a TAVI. An active pacemaker lead was fixed in the right ventricle via jugular access and a right transfemoral TAVI was performed. However, during the balloon aortic valvuloplasty, the procedure was complicated by severe arterial hypotension with a mean arterial pressure (MAP) of 33<span class="elsevierStyleHsp" style=""></span>mmHg for which norepinephrine (0.56<span class="elsevierStyleHsp" style=""></span>mcg/kg/min), vasopressin (0.1<span class="elsevierStyleHsp" style=""></span>U/kg/min) and dobutamine (5<span class="elsevierStyleHsp" style=""></span>mcg/kg/min) were started with a slightly increased MAP at 51<span class="elsevierStyleHsp" style=""></span>mmHg. Subsequently, the patient suffered cardiac arrest with ventricular fibrillation and pulseless electrical activity, therefore advanced cardiac life support was initiated. During the resuscitation, a self-expanding 29<span class="elsevierStyleHsp" style=""></span>mm biologic aortic valve prosthesis was advanced and successfully implanted, resulting in the return of spontaneous circulation with pacemaker dependency. An emergent coronary angiography was performed and ruled out coronary artery occlusion and no bleeding sites were detected. TTE showed good prosthesis function with no paravalvular leaks, mildly reduced systolic function, an LVOT peak gradient of 23<span class="elsevierStyleHsp" style=""></span>mmHg (previously 2<span class="elsevierStyleHsp" style=""></span>mmHg) and a peak velocity of 2.4<span class="elsevierStyleHsp" style=""></span>m/s. No SAM of the mitral valve was documented (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). As an SLV was suspected a 2<span class="elsevierStyleHsp" style=""></span>L of fluid resuscitation with Hartman solution was started and dobutamine was suspended.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">In the next 30<span class="elsevierStyleHsp" style=""></span>min, the patient presented with intermittent episodes of ventricular fibrillation, pulseless electrical activity, and persistent hemodynamic deterioration (MAP 53<span class="elsevierStyleHsp" style=""></span>mmHg, lactate 3.3<span class="elsevierStyleHsp" style=""></span>mmol/L) despite escalating vasopressor support. As there was no response to medical treatment, therapy was escalated to mechanical circulatory support using peripheral veno-arterial (VA) ECMO (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). A 23<span class="elsevierStyleHsp" style=""></span>Fr left femoral extraction venous multi-fenestrated cannula (Medtronic, Minneapolis, MN, USA) was placed at the Cavo atrial junction, a 17<span class="elsevierStyleHsp" style=""></span>Fr left arterial femoral return cannula (Medtronic) was placed, and a 6<span class="elsevierStyleHsp" style=""></span>Fr distal perfusion line was placed in the left superficial femoral artery. Assistance was started at 3000<span class="elsevierStyleHsp" style=""></span>rpm, with a flow of 3.4<span class="elsevierStyleHsp" style=""></span>L/min.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was transferred to the cardiovascular intensive care unit, where he was found to have an adequate post-resuscitation clinical neurological status (Full Outline of UnResponsiveness score 13) and CT ruled out anoxic-ischemic lesions. In the first 48<span class="elsevierStyleHsp" style=""></span>h, the patient demonstrated clinical improvement and was successfully extubated. At 72<span class="elsevierStyleHsp" style=""></span>h, vital signs stabilized (MAP 96<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate 85<span class="elsevierStyleHsp" style=""></span>beats per minute, oxygen saturation 95%), bedside echocardiogram showed left ventricular contractility improvement, and vasoactive support was reduced (norepinephrine 0.1<span class="elsevierStyleHsp" style=""></span>mcg/kg/min). Laboratory results showed a lactate level of 1.0 and creatinine elevation peaked at 1.7<span class="elsevierStyleHsp" style=""></span>mg/dL with gradual decrease in the following days (baseline 1.1<span class="elsevierStyleHsp" style=""></span>mg/dL). ECMO flow was reduced to 1.0<span class="elsevierStyleHsp" style=""></span>L/min with good tolerance. Due to improved hemodynamic status and meeting prognostic success criteria, the patient was transferred to the hemodynamics department, where he was decannulated after 3 days of assistance under fluoroscopic vision. The femoral artery was closed with a vascular closure device and direct pressure was applied to the femoral vein. The vasopressor support was discontinued 24<span class="elsevierStyleHsp" style=""></span>h later.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Six days after the procedure, his condition continued to improve, TTE revealed a residual intraventricular gradient of 15<span class="elsevierStyleHsp" style=""></span>mmHg, adequate aortic prosthesis position, leaflet excursion, and no paravalvular leaks. The patient was discharged after 11 days of hospitalization in compensated status.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">TAVI is a minimally invasive procedure used in patients diagnosed with severe aortic stenosis. Among its complications, a phenomenon known as SLV has been described. This is characterized by the development of dynamic intraventricular gradients, left ventricle hypercontractility, and/or systolic anterior motion of the mitral valve, after a sudden reduction in afterload, leading to dynamic obstruction of the LVOT and hemodynamic collapse.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">We present the case of a 75-year-old male who experienced severe hypotension and multiple episodes of cardiac arrest while undergoing TAVI. After ruling out the most common acute complications, SLV was considered. Predictive factors in our patient for developing SLV were a sigmoid-shaped septum, increased basal septal thickness (18<span class="elsevierStyleHsp" style=""></span>mm), a narrow LVOT (15<span class="elsevierStyleHsp" style=""></span>mm), a small hypertrophied ventricular cavity, and high pre-procedural valve gradients.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Regardless of the described conservative treatment,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> our patient experienced refractory cardiogenic shock and cardiac arrest during the TAVI procedure. As a result, early support with VA-ECMO was initiated, leading to the optimization of hemodynamic parameters, improvement of cardiac function, and stabilization of the patient preventing further end-organ damage.</p><p id="par0070" class="elsevierStylePara elsevierViewall">While this complication is rare, it is crucial to understand its characteristics, pathophysiology, preventive and therapeutic measures due to its increased mortality risk.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Whereas SLV is suspected, the conventional management of cardiogenic shock should be modified to encourage increasing filling pressures, raising diastolic filling time, and reducing inotropy; inotropes, vasodilators, and intra-aortic balloon pumps can aggravate the LVOT obstruction, promoting further instability.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Other strategies such as intended desynchronization of the left ventricle via right ventricular pacing, and more invasive and permanent procedures such as surgical myomectomy, and alcohol septal ablation have also been described as bail-out measures for SLV refractory to medical treatment. Nonetheless, these can represent a high risk in patients undergoing TAVI due to their comorbidities and frailty.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,3,4,6</span></a> So it is questionable whether these measures are strictly necessary, especially in this group of patients, as ECMO assistance can help stabilize the patient while the hemodynamics are optimized and the SLV is reversed.</p><p id="par0080" class="elsevierStylePara elsevierViewall">SLV scenarios in which ECMO therapy becomes more relevant and could be considered as a rescue strategy include (1) No adequate response to initial medical treatment where the obstruction further deteriorates hemodynamic status to a cardiogenic shock state. (2) Patient presents cardiorespiratory arrest refractory to advanced cardiac life support measures.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion(s)</span><p id="par0085" class="elsevierStylePara elsevierViewall">Sudden hemodynamic collapse during or following TAVI must include SLV as a differential diagnosis for prompt treatment and stabilization. This condition should be suspected when severe hypotension, high intraventricular gradients, and/or the presence of systolic anterior motion of the mitral valve are present. If the patient is stable, it is reasonable to start conservative treatment with intravenous fluids and beta-blockers, however, if the patient is unstable, the use of pure vasoconstrictors and early hemodynamic support with VA-ECMO can improve the patient's outcomes. To prevent LVOT obstruction from worsening, any measure that reduces the afterload or increases the left ventricle contractility must be avoided when SLV is suspected.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of human and animal subjects</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Ethical considerations</span><p id="par0105" class="elsevierStylePara elsevierViewall">The patient's anonymity has been maintained, written informed consent was obtained from the patient.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Funding</span><p id="par0110" class="elsevierStylePara elsevierViewall">None funding or other forms of financial support were received.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflict of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have nothing to disclose.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres2285590" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1900860" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1900858" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres2285591" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1900859" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:2 [ "identificador" => "sec0010" "titulo" => "Text" ] 7 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion(s)" ] 9 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0045" "titulo" => "Ethical considerations" ] 11 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 12 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-05-22" "fechaAceptado" => "2024-07-25" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1900860" "palabras" => array:5 [ 0 => "ECMO" 1 => "Cardiogenic shock" 2 => "Transcatheter aortic valve implantation" 3 => "Aortic valve stenosis" 4 => "Suicide left ventricle" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1900858" "palabras" => array:9 [ 0 => "TAVI" 1 => "SAVR" 2 => "SLV" 3 => "TTE" 4 => "LVEF" 5 => "LVOT" 6 => "ECMO" 7 => "MAP" 8 => "VA" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1900859" "palabras" => array:5 [ 0 => "ECMO" 1 => "Choque cardiogénico" 2 => "Implantación valvular aórtica transcateter" 3 => "Estenosis aórtica" 4 => "Ventrículo izquierdo suicida" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transcatheter aortic valve replacement is a minimally invasive procedure being increasingly used in patients diagnosed with severe aortic stenosis. Although considered rare, a phenomenon known as “suicide left ventricle” has been described. The most accepted pathophysiology mechanism involves a sudden significant afterload reduction that results in the dynamic obstruction of the left ventricular outflow tract and consequently hemodynamic collapse. Management of suicide left ventricle includes strategies aimed at increasing filling pressures, raising diastolic filling time, and reducing inotropy. However, if no response is observed, or the patient presents with severe hemodynamic compromise, extracorporeal membrane oxygenation therapy may be considered as a rescue strategy for severe, refractory cardiogenic shock. In this article, we report the case of a 75-year-old male who developed severe hemodynamic instability while undergoing transcatheter aortic valve implantation, secondary to suicide left ventricle. Therefore, extracorporeal membrane oxygenation support was initiated leading to a favorable evolution and hemodynamic improvement.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La implantación valvular aórtica transcateter es un procedimiento mínimamente invasivo que se utiliza cada vez más en pacientes diagnosticados con estenosis aórtica grave. Aunque se considera infrecuente, se ha descrito un fenómeno conocido como «ventrículo izquierdo suicida». Su mecanismo fisiopatológico más aceptado implica una reducción repentina de la postcarga que resulta en la obstrucción dinámica del tracto de salida del ventrículo izquierdo y, consecuentemente, colapso hemodinámico. El manejo del ventrículo izquierdo suicida incluye estrategias dirigidas a incrementar las presiones de llenado ventricular, prolongar el tiempo de llenado diastólico y reducir el inotropismo. Sin embargo, si no se observa respuesta al tratamiento o el paciente se presenta con un compromiso hemodinámico severo, la terapia con circulación por membrana extracorpórea puede considerarse como una estrategia de rescate para el choque cardiogénico refractario. En este artículo presentamos el caso de un hombre de 75 años que desarrolló inestabilidad hemodinámica severa durante la implantación valvular aórtica transcateter, secundaria a ventrículo izquierdo suicida. Por lo tanto, se inició el soporte con circulación por membrana extracorpórea, lo que conllevó a una evolución favorable y mejoría hemodinámica.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 886 "Ancho" => 2533 "Tamanyo" => 142167 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Preoperative transthoracic echocardiogram. (A) Long axis parasternal view showing LV hypertrophy and a small LV cavity. (B) 3D aortic valve reconstruction revealing severe stenosis. LV<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>left ventricle.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1157 "Ancho" => 3167 "Tamanyo" => 335426 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Immediate post-TAVI transthoracic echocardiogram. Continuous wave Doppler showing (A) intraventricular gradient of 23<span class="elsevierStyleHsp" style=""></span>mmHg and maximum velocity of 2.4<span class="elsevierStyleHsp" style=""></span>m/s, no SAM of the mitral valve was documented, (B) LV mid-cavitary gradient. LV<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>left ventricle, TAVI<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>transcatheter aortic valve implantation, SAM<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>systolic anterior motion.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 952 "Ancho" => 1934 "Tamanyo" => 135385 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Percutaneous ECMO cannulation with ultrasound-guided puncture and fluoroscopic guidance, following trans aortic valve implantation. (A) White arrow indicates the left femoral extraction venous cannula placed at the Cavo atrial junction. (B) Black arrow indicates the return cannula placed in the left superficial femoral artery. The right femoral artery was used for valve implantation and balloon valvuloplasty. ECMO<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>extracorporeal membrane oxygenation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Overcoming the obstacle of suicide left ventricle after transcatheter aortic valve replacement phenomenon" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "L. Koliastasis" 1 => "M. Drakopoulou" 2 => "G. 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