Cardiovascular Critical Care I
Highest risk within the first year after replacement
Treatment involves systemic fibrinolytic treatment or surgical reoperation with varying success rates –
Both carry significant risks of morbidity and mortality, including:
Thrombolysis (predominantly recommended for right-sided valve thrombosis)
Cardiac tamponade
ii.
Stroke/transient ischemic attack
iii.
Systemic embolization
iv.
Major bleeding
Death
Surgery (predominantly recommended for left-sided valve thrombosis)
Cardiac tamponade
ii.
Stroke/transient ischemic attack
iii.
Renal failure
iv.
Heart block
Systemic embolization
vi.
Prolonged ventilation
vii.
Major bleeding
viii.
Death
Other Cardiac Functional Defects
Left ventricular outflow tract (LVOT) obstruction (Circulation 2020;142:e558-e631; Circulation
2008;117:429-39; J Am Coll Cardiol 2000;36:1344-54)
Hypertrophic obstructive cardiomyopathy (HOCM)
Genetic disease leading to hypertrophy of the LV (particularly the ventricular septum) with or
without the presence of LV outflow tract obstruction
ii.
LVOT obstruction is of greatest concern when HOCM exists with systolic anterior motion
(SAM) (see text that follows); however, in HOCM, LVOT obstruction can exist in the absence of
SAM because of septal hypertrophy; nonetheless, acute clinical management is predominantly
the same as outlined in 1.a.i–iii and in 1.b.i.
iii.
Treatment of HOCM without SAM relies heavily on the management of contributors to
myocardial hypertrophy and diastolic HF.
| (a) | Non-vasodilating β-blockers are first-line agents in the treatment of patients with HOCM |
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and are commonly titrated to heart rate goals of 60–65 beats/minute.
| (b) | Dihydropyridine calcium channel blockers (particularly verapamil) are recommended |
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in patients with contraindications to β-blockade or in those without advanced HF or
bradycardia.
| (c) | For recommendations specific to HOCM (patients also with SAM), see “b” in the text that |
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follows.
| (d) | Patients with HOCM may be at increased risk of sudden cardiac death. Evaluation should |
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consider the patient’s candidacy for implantable cardioverter-defibrillator placement by
ambulatory ECG (Holter) monitoring at least biannually.
iv.
Treatment may be indicated by surgical septal myectomy or catheter-directed alcohol ablation.
SAM of the mitral valve
SAM and LVOT obstructions result in a systolic outflow tract obstruction and are commonly
associated with HOCM but can also occur in other clinical scenarios, particularly after cardiac
surgery.