J Cardiovasc Ultrasound.  2016 Jun;24(2):158-162. 10.4250/jcu.2016.24.2.158.

Pregnancy in Hypertrophic Cardiomyopathy with Severe Left Ventricular Outflow Tract Obstruction

• Shin J
• Kim M
• Lee J
• Kim S
• Kim M
• Hwang H
• Moon J
• Shin MS
• Chung WJ

• KMID: 2308706
• DOI: http://doi.org/10.4250/jcu.2016.24.2.158

Abstract

Hypertrophic obstructive cardiomyopathy (HOCM) patients with severe left ventricular outflow tract (LVOT) obstruction (those with a gradient of > 100 mm Hg) are at the highest risk of hemodynamic deterioration during pregnancy. Complications of HOCM include sudden cardiac death, heart failure, and arrhythmias. Physiological changes during pregnancy may induce these complications, affecting maternal and fetal health conditions. Therefore, close monitoring with appropriate management is essential for the well-being of both mother and fetus. We report on the case of a 27-year-old female patient with severe LVOT obstruction HOCM, pressure gradient (PG) of 125 mm Hg at resting, and 152 mm Hg induced by the Valsalva maneuver at 34 weeks gestation. This case showed how close monitoring using echocardiography and proper management during the course of pregnancy resulted in successful delivery in the patient with extremely high PG HOCM.

Keyword

Hypertrophic cardiomyopathy; Left ventricular outflow obstruction; High risk pregnancy; Echocardiography

MeSH Terms

Adult
Arrhythmias, Cardiac
Cardiomyopathy, Hypertrophic*
Death, Sudden, Cardiac
Echocardiography
Female
Fetus
Heart Failure
Hemodynamics
Humans
Mothers
Pregnancy*
Pregnancy, High-Risk
Valsalva Maneuver
Ventricular Outflow Obstruction

Figure

• 

  Fig. 1 Baseline transthoracic echocardiography (TTE). TTE showed massive asymmetric septal hypertrophy of left ventricular septum with wall thickness > 22 mm in parasternal long axis view (A), eccentric mitral regurgitation grade III/IV (B), systolic anterior motion (white arrow) of mitral valve presented by M-mode (C), very high left ventricular outflow tract pressure gradient at resting (D), and during the Valsalva maneuver (E).

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  Fig. 2 Serial check up of left ventricular outflow tract (LVOT) pressure gradient (PG) presented by M-mode at resting (A) and during the Valsalva maneuver (B). At 11 weeks gestation, initial transthoracic echocardiography examination showed LVOT PG (peak/mean PG; 75/47 mm Hg at rest, 103/52 mm Hg during Valsalva maneuver). As the pregnancy progresses, when 34 weeks gestation, LVOT PG was increasing up to 125/63 mm Hg at resting and 152/72 mm Hg on the Valsalva maneuver.

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  Fig. 3 Serial follow up of left ventricular outflow tract (LVOT) pressure during pregnancy. This graph shows the serial values of LVOT PG at resting (blue line) and during the Valsalva maneuver (red line) which changes according to the gestational age. PG: pressure gradient.

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  Fig. 4 Transthoracic echocardiography (TTE) and cardiac catheterization just before the alcohol septal ablation. TTE showed severe left ventricular outflow tract (LVOT) pressure gradient (PG) (A) and cardiac catheterization showed also high LVOT PG (127 mm Hg) at the same time (B). Ao: aorta, LV: left ventricle.

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