55. Case Report: Suicide LV post-TAVR – The University of Texas at Austin, Dell Medical School

Transcatheter aortic valve replacement (TAVR) offers life-saving treatment for severe aortic stenosis, yet it carries risks of life-threatening periprocedural complications. A 71-year-old patient’s post-TAVR cardiogenic shock—characterized by profound hypotension and PEA arrest—highlights the clinical necessity of a systematic, hypothesis-driven diagnostic approach. While initial concerns included hemorrhage, tamponade, or coronary obstruction, bedside echocardiography revealed a hyperdynamic left ventricle with intracavitary obstruction, identifying "suicide LV." This condition, triggered by a protamine-induced anaphylactoid reaction and exacerbated by aggressive inotropic support, requires counterintuitive management: volume resuscitation, withdrawal of inotropes, and the use of pure alpha-agonists to maintain preload and afterload. Recognizing patient-specific risk factors, such as small LV cavity size and asymmetric septal hypertrophy, remains critical for preventing this obstructive physiology. Effective management relies on rapid hemodynamic assessment and the ability to pivot therapeutic strategies based on real-time physiological data.