A 57‐year‐old woman with no significant past medical history was admitted to the cardiac intensive care unit following an out‐of‐hospital cardiac arrest of approximately 50‐min duration. The diagnosis of bilateral pulmonary emboli was made via pulmonary computed tomographic angiography, and thrombolysis with alteplase was administered. A transoesophageal echocardiogram showed a dilated and hypokinetic right ventricle, with systolic anterior motion of the anterior mitral valve leaflet, causing left ventricular outflow tract (LVOT) obstruction (Video S1). The clinical condition of the patient continued to worsen despite thrombolysis, with significant hypotension necessitating central venous infusions of high‐dose adrenaline, noradrenaline, vasopressin and milrinone. In view of the systolic anterior motion seen on echocardiography, an esmolol infusion was commenced.
Over the course of the next day, her condition improved significantly, and her inotropic and vasopressor requirements decreased. Serial echocardiography revealed a gradual decrease in LVOT velocity and systolic anterior motion of the anterior mitral leaflet. The patient made excellent progress and was discharged from intensive care after 37 days.
Acute pulmonary embolism causes LVOT obstruction by increasing right ventricular pressure, resulting in leftward deviation of the interventricular septum. Accelerated blood flow causes drag forces on the anterior mitral leaflet resulting in systolic anterior motion of the mitral valve [1]. For haemodynamically compromised patients with LVOT obstruction secondary to acute pulmonary embolism, thrombolysis and mechanical thrombectomy have been shown to be successful [2, 3]. Beta‐blockade in the scenario of LVOT obstruction likely yields haemodynamic stability through increasing left ventricular filling time and size. In summary, we describe a case where beta‐blockade with an intravenous infusion of esmolol was successfully used to treat shock secondary to LVOT obstruction in acute pulmonary embolism.
Supporting information
Video S1. Four chamber and long axis views demonstrating left ventricular outflow tract obstruction secondary to systolic anterior motion of the anterior mitral valve leaflet. https://youtu.be/isUXZQvSdvY
Acknowledgements
Published with the written consent of the patient. No external funding or competing interests declared.
Contributor Information
A. Hill, Email: amyhill@doctors.org.uk, @amyhill7017590.
O. Al Rawi, @OMARALRAWI5.
References
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Supplementary Materials
Video S1. Four chamber and long axis views demonstrating left ventricular outflow tract obstruction secondary to systolic anterior motion of the anterior mitral valve leaflet. https://youtu.be/isUXZQvSdvY