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Cyclic Appearance of Left Ventricular Outflow Tract Dynamic Obstruction During Mechanical Ventilation: Evidence for a Preload Dependent Phenomenon

Departments of General Intensive Care, University Hospital Centre, University of Liege, Domaine Universitaire du Sart-Tilman, Jean-Luc.Canivet{at}chu.ulg.ac.be

Patrizio Lancellotti, MD, PhD

Department of Cardiology, University Hospital Centre, University of Liege, Domaine Universitaire du Sart-Tilman

Marc Radermecker, MD, PhD

Department of Cardiothoracic and Vascular Surgery, University Hospital Centre, University of Liege, Domaine Universitaire du Sart-Tilman, Liege, Belgium

Pierre Damas, MD, PhD

Departments of General Intensive Care, University Hospital Centre, University of Liege, Domaine Universitaire du Sart-Tilman

The cyclic appearance of dynamic left ventricular outflow tract obstruction during mechanical ventilation, according to the phasic changes in preload, is described in this article. Hemodialysis-induced fluid removal resulted in preload dependence as evidenced by the pulse pressure variation in a 56-year-old critically ill patient. The clinical picture was suggestive of myocardial failure. Transthoracic echocardiography disclosed dynamic left ventricular outflow tract obstruction associated with systolic anterior motion of the mitral valve. Progressive fluid restitution resulted in a parallel decrease in both the degree of dynamic obstruction and pulse pressure variation. During fluid loading, dynamic obstruction disappeared at first during the inspiratory phase of intermittent positive pressure ventilation corresponding to the phasic increase in left ventricular preload. Further fluid loading resulted in the disappearance of dynamic obstruction during both inspiratory and expiratory phase of intermittent positive pressure ventilation. This is the first reported case clearly relating left ventricular outflow tract dynamic obstruction to preload dependence during mechanical ventilation in a critically ill patient without predisposing anatomical factor.

Key Words: dynamic left ventricular outflow tract obstruction • mechanical ventilation • preload dependence

This version was published on July 1, 2008

Journal of Intensive Care Medicine, Vol. 23, No. 4, 281-284 (2008)
DOI: 10.1177/0885066608318662


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