Author + information
- Malini Madhavan, MBBS,
- Sorin V. Pislaru, MD and
- Abhiram Prasad, MD⁎ ()
- ↵⁎Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905
We thank Drs. Shah and Curzen for their interest in our recent paper (1). Among the 118 patients in our study, 92 underwent left ventriculography, and mitral regurgitation (MR) was quantified as grade 1, 2, 3, and 4 in 27%, 16%, 9%, and 5%, respectively. Grade 3 or 4 MR was associated with lower left ventricular ejection fraction (median 35% [interquartile range: 22% to 44%] vs. 45% [interquartile range: 33% to 51%], p = 0.02), higher incidence of left ventricular outflow tract (LVOT) obstruction (36% vs. 7%, p = 0.02), and heart failure (HF) (62% vs. 39%, p = 0.08). Twelve of the 13 patients with grade 3 or 4 MR underwent echocardiography, which identified LVOT obstruction and systolic anterior motion of the anterior mitral leaflet (n = 4), tethering of the anterior mitral leaflet (n = 5), and degenerative mitral valve disease (n = 3) as the potential mechanisms for valve dysfunction. Follow-up echocardiography demonstrated complete resolution of MR in 54% and mild residual MR in the remaining patients.
LVOT obstruction was detected by echocardiography in 10%. The occurrence of LVOT obstruction was not significantly different among patients with and without HF (8% vs. 13%, p = 0.5). The 4 patients with HF who also had LVOT obstruction all demonstrated grade 3 or 4 MR, and cardiogenic shock developed in 2 patients. An intra-aortic balloon pump was not used in these patients. All 4 had complete resolution of HF at the time of discharge, and a follow-up echocardiogram showed resolution of LVOT obstruction and normalization of left ventricular systolic function.
Thus, we agree with Drs. Shah and Curzen that significant MR may be present and appears to be more prevalent in patients with HF, but it is reversible. LVOT obstruction was noted in 10% of the cohort and when present in patients with HF, coexisted with grade 3 or 4 MR. We recommend that patients with apical ballooning syndrome and severe HF and/or hypotension undergo echocardiography to detect LVOT obstruction because its presence should modify management. These patients are best treated with careful fluid management to avoid excessive preload reduction, beta-blockers (if tolerated), and occasionally peripheral vasoconstrictors.
- American College of Cardiology Foundation