Limits...
Exercise-Stress Echocardiography Reveals Systolic Anterior Motion of the Mitral Valve as a Cause of Syncopes in a Cardiac Amyloidosis Patient

View Article: PubMed Central - PubMed

ABSTRACT

Patients with cardiac amyloidosis are at increased AV-block and syncope risk. Therefore, a prophylactic pacemaker is often implanted. However, this case illustrates that other mechanisms should be ruled out prior to pacemaker implantation. The patient studied had mitral valve thickening without increased left ventricular outflow track (LVOT) velocity. However, bicycle exercise-stress test with simultaneous echocardiography revealed a stepwise decrease in blood pressure, a substantial increase in the LVOT velocity, and severe systolic anterior motion of the mitral valve. The patients' symptoms were likely explained by these findings. Therefore, a comprehensive clinical evaluation is warranted prior to pacemaker implantation in cardiac amyloidosis patients.

No MeSH data available.


(a) Electrocardiogram. (b) Echocardiographic apical four-chamber view.
© Copyright Policy
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC5121456&req=5

fig1: (a) Electrocardiogram. (b) Echocardiographic apical four-chamber view.

Mentions: Electrocardiogram revealed low-voltage limb leads and first degree of AV-block (Figure 1(a)). Echocardiogram revealed thickened left ventricle (LV) walls with a septal thickness of 18 mm and posterior wall of 16 mm (Figure 1(b)). The LV cavity was small with end-diastolic diameter of 34 mm and end-systolic diameter of 21 mm. The mitral valve was thickened and mild systolic anterior motion (SAM) was noted. However, left ventricular outflow track (LVOT) velocity was normal at 1.3 m/s both at rest and during the Valsalva maneuver. Ejection fraction was 70% but long-axis function severely reduced with global longitudinal strain at −10.1%. Apical sparing was noted. Coronary flow reserve was measured by Doppler echocardiography. CFR was severely reduced at 1.2 (normal range >2.5–4.5). Cardiac amyloidosis (CA) was suspected and the patient was referred for endomyocardial biopsy. This revealed extensive amyloid infiltration (Figure 2). Immunohistochemistry was positive for λ-light chains and negative for transthyretin, amyloid A, and κ-light chains.


Exercise-Stress Echocardiography Reveals Systolic Anterior Motion of the Mitral Valve as a Cause of Syncopes in a Cardiac Amyloidosis Patient
(a) Electrocardiogram. (b) Echocardiographic apical four-chamber view.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5121456&req=5

fig1: (a) Electrocardiogram. (b) Echocardiographic apical four-chamber view.
Mentions: Electrocardiogram revealed low-voltage limb leads and first degree of AV-block (Figure 1(a)). Echocardiogram revealed thickened left ventricle (LV) walls with a septal thickness of 18 mm and posterior wall of 16 mm (Figure 1(b)). The LV cavity was small with end-diastolic diameter of 34 mm and end-systolic diameter of 21 mm. The mitral valve was thickened and mild systolic anterior motion (SAM) was noted. However, left ventricular outflow track (LVOT) velocity was normal at 1.3 m/s both at rest and during the Valsalva maneuver. Ejection fraction was 70% but long-axis function severely reduced with global longitudinal strain at −10.1%. Apical sparing was noted. Coronary flow reserve was measured by Doppler echocardiography. CFR was severely reduced at 1.2 (normal range >2.5–4.5). Cardiac amyloidosis (CA) was suspected and the patient was referred for endomyocardial biopsy. This revealed extensive amyloid infiltration (Figure 2). Immunohistochemistry was positive for λ-light chains and negative for transthyretin, amyloid A, and κ-light chains.

View Article: PubMed Central - PubMed

ABSTRACT

Patients with cardiac amyloidosis are at increased AV-block and syncope risk. Therefore, a prophylactic pacemaker is often implanted. However, this case illustrates that other mechanisms should be ruled out prior to pacemaker implantation. The patient studied had mitral valve thickening without increased left ventricular outflow track (LVOT) velocity. However, bicycle exercise-stress test with simultaneous echocardiography revealed a stepwise decrease in blood pressure, a substantial increase in the LVOT velocity, and severe systolic anterior motion of the mitral valve. The patients' symptoms were likely explained by these findings. Therefore, a comprehensive clinical evaluation is warranted prior to pacemaker implantation in cardiac amyloidosis patients.

No MeSH data available.