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0885066608318662v1
23/4/281    most recent
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First published on May 28, 2008, doi:10.1177/0885066608318662

Journal of Intensive Care Medicine 2008;23:281.

A more recent version of this article appeared on July 1, 2008

Article

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

Jean-Luc Canivet, MD1*, Patrizio Lancellotti, MD, Ph.D.2, Marc Radermecker, MD, PhD3, and Pierre Damas, MD, Ph.D.4

1 Department of General Intensive Care
2 Dept of Cardiology
3 Dept of Cardiothoracic and Vascular Surgery
4 Centre Hospitalier Universitaire de Liege

* To whom correspondence should be addressed. E-mail: jean-luc.canivet{at}chu.ulg.ac.be.


  Abstract
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.


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