Sargent Stephanie, Xiong Eddy, Lau Katherine, Raffel Owen Christopher, Greaves Kim
Cardiology Department, Sunshine Coast University Hospital, 6 Doherty Street, Birtinya, 4575 Queensland, Australia.
School of Medicine, Griffith University, 6 Doherty Street, Birtinya, 4575 Queensland, Australia.
Eur Heart J Case Rep. 2025 Feb 14;9(4):ytaf081. doi: 10.1093/ehjcr/ytaf081. eCollection 2025 Apr.
Neo-left ventricular outflow tract (LVOT) obstruction is a dreaded complication following transcatheter mitral valve replacement (TMVR). Dynamic LVOT obstruction has been reported to cause mechanical intravascular haemolysis due to red cell fragmentation. Intravascular haemolysis can result in a rare but well-described phenomenon in which patients experience dysphagia due to oesophageal spasm. This phenomenon is classically associated with paroxysmal nocturnal haemoglobinuria and has never been reported following TMVR.
A 77-year-old female presented 8 days following TMVR with presyncope, dyspnoea, and severe dysphagia. Transthoracic echocardiography revealed neo-LVOT obstruction with trivial paravalvular mitral regurgitation. Doppler echocardiography revealed dynamic late-peaking LVOT obstruction with a peak gradient of 71 mmHg with Valsalva manoeuvre. Laboratory investigations demonstrated intravascular haemolytic anaemia. A barium swallow was performed revealing severe diffuse oesophageal spasm. Alternative causes of dysphagia were excluded, and a causal link between intravascular haemolysis and dysphagia was identified. Successful management of dynamic neo-LVOT obstruction, haemolytic anaemia, and dysphagia was achieved with beta blocker therapy and volume resuscitation. Serial echocardiography and barium swallow performed prior to discharge demonstrated resolution of LVOT obstruction and marked reduction in oesophageal spasm.
To our knowledge, this is the first case report of TMVR complicated by reversible neo-LVOT obstruction with only trivial paravalvular regurgitation causing intravascular haemolysis and subsequent dysphagia. The management of dysphagia secondary to intravascular haemolysis due to neo-LVOT obstruction is challenging. This is because of the complex haemodynamic interplay between reduced oral intake, a high output state with anaemia, increased ventricular contractility, tachycardia, and worsening dynamic obstruction, all part of a vicious cycle ().
新发性左心室流出道（LVOT）梗阻是经导管二尖瓣置换术（TMVR）后一种可怕的并发症。据报道，动态LVOT梗阻会因红细胞破碎导致机械性血管内溶血。血管内溶血可导致一种罕见但有详细描述的现象，即患者因食管痉挛而出现吞咽困难。这种现象典型地与阵发性夜间血红蛋白尿相关，在TMVR后从未有过报道。
一名77岁女性在TMVR术后8天出现晕厥前症状、呼吸困难和严重吞咽困难。经胸超声心动图显示新发性LVOT梗阻，伴有轻微瓣周二尖瓣反流。多普勒超声心动图显示动态晚期峰值LVOT梗阻，Valsalva动作时峰值压差为71 mmHg。实验室检查显示血管内溶血性贫血。进行了钡餐检查，显示严重的弥漫性食管痉挛。排除了吞咽困难的其他原因，并确定了血管内溶血与吞咽困难之间的因果关系。通过β受体阻滞剂治疗和容量复苏成功地处理了动态新发性LVOT梗阻、溶血性贫血和吞咽困难。出院前进行的系列超声心动图和钡餐检查显示LVOT梗阻得到缓解，食管痉挛明显减轻。
据我们所知，这是首例TMVR并发可逆性新发性LVOT梗阻的病例报告，仅有轻微瓣周反流导致血管内溶血及随后的吞咽困难。处理因新发性LVOT梗阻导致血管内溶血继发的吞咽困难具有挑战性。这是因为减少经口摄入量、贫血导致的高输出状态、心室收缩力增加、心动过速以及动态梗阻加重之间存在复杂的血流动力学相互作用，所有这些都构成了一个恶性循环（）。
