Managing the High-Risk Patient: Critical Care, TAVR, MitraClip, Pressors, and Cardiac Assist Devices

  • Timothy C. WongEmail author
  • Eugene C. DePasquale
  • Arnold S. Baas


The hypertrophic cardiomyopathy (HCM) phenotypes, including left ventricular outflow tract obstruction as well as diastolic and systolic heart failure, are encountered periodically in the critical care setting. An understanding of diagnostic evaluation and therapeutic management in the acutely ill patient with HCM will enable caregivers to optimize cardiovascular outcomes. This chapter will discuss management of several acute care scenarios by which HCM patients may present, including medical therapy as well as more advanced options. In addition, the rapidly expanding field of percutaneous intervention for structural heart disease offers novel therapy for outflow obstruction in addition to traditional surgical intervention. Acute management of potential complications following structural heart disease procedures will be discussed. Finally, case studies will be presented to provide a real-world experience of high-risk HCM patients in the acute setting.


High risk Critical care Vasopressors Inotropes MitraClip Assist device 


  1. 1.
    Gersh BJ, Maron BJ, Bonow RO, et al. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: a report of the American College of cardiology foundation/American heart association task force on practice guidelines. Circulation. 2011, 124(24)Google Scholar
  2. 2.
    Chauvet JL, El-Dash S, Delastre O, et al. Early dynamic left intraventricular obstruction is associated with hypovolemia and high mortality in septic shock patients. Crit Care [Internet]. 2015;19(1):1–8. Available from:. Scholar
  3. 3.
    Said SM, Schaff HV, Suri RM, Greason KL, Dearani JA, Nishimura RA. Bulging subaortic septum: an important risk factor for systolic anterior motion after mitral valve repair. Ann Thorac Surg [Internet]. 2011;91(5):1427–32. Available from: CrossRefGoogle Scholar
  4. 4.
    Sharkey SW, Windenburg DC, Lesser JR, et al. Natural history and expansive clinical profile of stress (Tako-Tsubo) cardiomyopathy. J Am Coll Cardiol [Internet]. 2010;55(4):333–41. Available from:. Scholar
  5. 5.
    Macintyre C, Lakdawala NK. Management of atrial fibrillation in hypertrophic cardiomyopathy. Circulation. 2016;133(19):1901–5.CrossRefGoogle Scholar
  6. 6.
    Sohn I-S, Kim J-N, Cho J-M, Kim C-J, Lee J-J. Witnessed massive pulmonary thromboembolism and dynamic left ventricular outflow tract obstruction. J Am Soc Echocardiogr [Internet]. 2009;22(1):105.e3–4. Available from:
  7. 7.
    Morelli A, Ertmer C, Westphal M, et al. Effect of heart rate control with esmolol on hemodynamic and clinical outcomes in patients with septic shock. JAMA [Internet]. 2013;310(16):1683. Available from: CrossRefGoogle Scholar
  8. 8.
    Sirak TE, Sherrid M V. Oral disopyramide for the acute treatment of severe outflow obstruction in hypertrophic cardiomyopathy in the ICU setting. Chest [Internet]. 2008;133(5):1243–6. Available from: CrossRefGoogle Scholar
  9. 9.
    Biagini E, Coccolo F, Ferlito M, et al. Dilated-hypokinetic evolution of hypertrophic cardiomyopathy: prevalence, incidence, risk factors, and prognostic implications in pediatric and adult patients. J Am Coll Cardiol [Internet]. 2005;46(8):1543–50. Available from:. Scholar
  10. 10.
    Olivotto I, Cecchi F, Poggesi C, Yacoub MH. Patterns of disease progression in hypertrophic cardiomyopathy an individualized approach to clinical staging. Circ Heart Fail. 2012;5(4):535–46.CrossRefGoogle Scholar
  11. 11.
    Maron BJ, Casey SA, Poliac LC, Gohman TE, Almquist AK, Aeppli DM. Clinical course of hypertrophic cardiomyopathy in a regional United States cohort. J Am Med Assoc. 1999;281(7):650–5.CrossRefGoogle Scholar
  12. 12.
    Melacini P, Basso C, Angelini A, et al. Clinicopathological profiles of progressive heart failure in hypertrophic cardiomyopathy. Eur Heart J. 2010;31(17):2111–23.CrossRefGoogle Scholar
  13. 13.
    Rowin EJ, Maron BJ, Kiernan MS, et al. Advanced heart failure with preserved systolic function under-recognized subset of candidates for heart transplant. Circ Heart Fail. 2014;70:967–75.CrossRefGoogle Scholar
  14. 14.
    Maron MS, Kalsmith BM, Udelson, JE, et al. Survival after cardiac transplantation in patients with hypertrophic cardiomyopathy. Circ Heart Fail. 2010;3:574–79.Google Scholar
  15. 15.
    Vanderpluym C, Graham DA, Almond CS, Blume ED, Milliren CE, Singh TP. Survival in patients removed from the heart transplant waiting list before receiving a transplant. J Hear Lung Transplant [Internet]. 2014;33(3):261–9. Available from:. Scholar
  16. 16.
    Topilsky Y, Pereira NL, Shah DK, et al. Left ventricular assist device therapy in patients with restrictive and hypertrophic cardiomyopathy. Circ Heart Fail. 2011;4(3):266–75.CrossRefGoogle Scholar
  17. 17.
    Deo S V., Park SJ. Centrifugal continuous-flow left ventricular assist device in patients with hypertrophic cardiomyopathy. ASAIO J [Internet] 2013;59(2):97–8. Available from: Scholar
  18. 18.
    Favaloro RR, Bertolotti A, Diez M, et al. Adequate systemic perfusion maintained by a CentriMag during acute heart failure. Tex Heart Inst J. 2008;35(3):334–9.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Cevik C, Nguyen HUT, Civitello AB, Simpson L. Percutaneous ventricular assist device in hypertrophic obstructive cardiomyopathy with cardiogenic shock: bridge to myectomy. Ann Thorac Surg [Internet]. 2012;93(3):978–80. Available from:. Scholar
  20. 20.
    Shenouda J, Silber D, Subramaniam M, et al. Evaluation and management of concomitant hypertrophic obstructive cardiomyopathy and valvular aortic stenosis. Curr Treat Options Cardiovasc Med. 2016;18(3):1–14.CrossRefGoogle Scholar
  21. 21.
    Krishnaswamy A, Tuzcu EM, Svensson LG, Kapadia SR. Combined transcatheter aortic valve replacement and emergent alcohol septal ablation. Circulation. 2013;128(18):366–9.CrossRefGoogle Scholar
  22. 22.
    Takeda Y, Nakatani S, Kuratani T, et al. Systolic anterior motion of the mitral valve and severe mitral regurgitation immediately after transcatheter aortic valve replacement. J Echocardiogr. 2012;10(4):143–5.CrossRefGoogle Scholar
  23. 23.
    Suh WM, Witzke CF, Palacios IF. Suicide left ventricle following transcatheter aortic valve implantation. Catheter Cardiovasc Interv. 2010;76(4):616–20.CrossRefGoogle Scholar
  24. 24.
    Hahn RT, Kodali S, Tuzcu EM, et al. Echocardiographic imaging of procedural complications during balloon-expandable transcatheter aortic valve replacement. JACC Cardiovasc Imaging [Internet]. 2015;8(3):288–318. Available from:. Scholar
  25. 25.
    López Ayerbe J, Evangelista Masip A, Armada Romero E, et al. Predictive factors of abnormal dynamic intraventricular gradient after valve replacement in severe aortic stenosis. Rev Esp Cardiol. 2002;55(2):127–34.CrossRefGoogle Scholar
  26. 26.
    Sorajja P, Pedersen WA, Bae R, et al. First experience with percutaneous mitral valve plication as primary therapy for symptomatic obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol [Internet]. 2016;67(24):2811–8. Available from:. Scholar
  27. 27.
    Sherrid MV, Barac I, McKenna WJ, et al. Multicenter study of the efficacy and safety of disopyramide in obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol. 2005;45(8):1251–8.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Timothy C. Wong
    • 1
    Email author
  • Eugene C. DePasquale
    • 2
  • Arnold S. Baas
    • 2
  1. 1.University of Pittsburgh School of Medicine, UPMC Heart and Vascular Institute - Hypertrophic Cardiomyopathy CenterPittsburghUSA
  2. 2.UCLA Advanced Heart Failure, Heart Transplantation and Mechanical Circulatory Support Program, UCLA Hypertrophic Cardiomyopathy ProgramDavid Geffen School of Medicine at UCLALos AngelesUSA

Personalised recommendations