ArticleCritical care (London, England)2025
Dynamic left ventricular outflow tract obstruction in critical illness: etiology-driven management and the role of bedside transthoracic echocardiography.
Article in Critical care (London, England), 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundDynamic left ventricular outflow tract obstruction (LVOTO) is an increasingly recognized life-threatening condition in critically ill patients, with ICU mortality rates reaching 53% in septic shock populations. Bedside transthoracic echocardiography (TTE) has become indispensable for early detection due to its diagnostic sensitivity and real-time monitoring capabilities in ICU settings. CASES: We present three prototypical cases managed at our tertiary center: (1) A 66-year-old male with volume depletion-induced LVOTO (peak gradient 29 mmHg) reversed by fluid resuscitation; (2) A 71-year-old female developing inotrope-induced obstruction (36 mmHg gradient) requiring β-blockade; and (3) A septic shock patient with severe LVOTO managed through combined fluid resuscitation, sedation, and vasopressor optimization. MANAGEMENT: Pathophysiology-guided interventions included: fluid resuscitation for hypovolemia (Case 1), analgesia/sedation for hypercontractility (Case 2), and norepinephrine for preload and afterload augmentation in sepsis (Case 3). Serial TTE monitoring confirmed gradient reductions. OUTCOMES: Early TTE-directed therapy achieved: (1) vasopressor weaning in 48 h (Case 1), (2) hemodynamic stabilization within 24 h (Case 2), and (3) septic shock reversal (Case 3).
conclusionLVOTO is a life-threatening yet underrecognized complication in critical care, requiring prompt and tailored management based on its diverse etiologies. Bedside TTE serves as an essential tool for rapid diagnosis, guiding targeted interventions, and optimizing outcomes in these high-risk patients. It should be stressed that almost all hypotensive patients in contemporary ICUs should receive bedside TTE as a standard of care, given its critical role in identifying underlying causes and informing timely treatment decisions.
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