A Delayed Case of “Suicide Ventricle” Post-TAVI Saved by Magnets and Alcohol

ANZET 2017 Certificate

I was selected as a finalist of the Geoff Mews Memorial ANZET Fellows’ Prize 2017 this year for my submission of an abstract with the title of “A Delayed Case of “Suicide Ventricle” Post-TAVI Saved by Magnets and Alcohol.

I presented the case at the ANZET Meeting 2017, but unfortunately did not win the prize.

Below is the abstract that I submitted.

A Delayed Case of “Suicide Ventricle” Post-TAVI Saved by Magnets and Alcohol

“Suicide ventricle” is a recognized phenomenon following Transcatheter Aortic Valve Implantation (TAVI) procedures. Here we present a delayed case of this phenomenon, saved by magnets and alcohol.

An 89 year old woman with severe aortic stenosis underwent TAVI. Her echocardiogram showed severe left ventricular hypertrophy, marked asymmetric septal hypertrophy, no dynamic left ventricular outflow tract (LVOT) gradient or systolic anterior motion (SAM) of the mitral leaflet. The procedure was uncomplicated with no evidence of SAM or LVOT obstruction peri-procedurally. Post-procedure, rapid AF developed. Her HR decreased to 50bpm with RV apical pacing. Echocardiogram showed no effusion, LVOT gradient or SAM. A septal permanent pacemaker was inserted due to persistent pacing dependence. Post-procedure her SBP dropped to 60mmHg and noradrenaline infusion was started. Her BP remained poor despite increasing doses and acute pulmonary oedema (APO) developed. Echocardiogram revealed a new LVOT gradient and SAM. Her HR was increased via magnet to the backup rate of 85bpm with immediate haemodynamic improvement. Noradrenaline was ceased. Alcohol septal ablation was considered and deferred due to improving haemodynamics. She remained well, but 5 days later developed APO. CPAP and frusemide were ineffective. Urgent alcohol septal ablation was performed with immediate improvement of her LVOT gradient. She was discharged 5 days later.

This case illustrates that a change in pacing location was sufficient to trigger LVOT obstruction with SAM and that a change in heart rate can result in a dramatic improvement in haemodynamics. Urgent alcohol septal ablation was life saving in this situation.