Suicide left ventricle triggered by accelerated junctional rhythm after transcatheter aortic valve implantation: a case report of rhythm-dependent dynamic left ventricular outflow tract obstruction

Suicide left ventricle (LV) is a rare, potentially fatal complication after transcatheter aortic valve implantation (TAVI). It is typically caused by dynamic left ventricular outflow tract obstruction (LVOTO) following abrupt afterload reduction. Accelerated junctional rhythm (AJR) is an uncommon peri-procedural arrhythmia, and its role in precipitating suicide LV has not been reported.

An 87-year-old woman with extremely severe aortic stenosis was admitted for transfemoral TAVI. Concentric LV hypertrophy with a sigmoid septum and preserved systolic function was observed on baseline transthoracic echocardiography. She developed profound hypotension immediately after valve deployment. Transoesophageal echocardiography (TOE) revealed severe LVOTO and marked mitral regurgitation (MR) due to systolic anterior motion (SAM) of the mitral valve. The simultaneous appearance of AJR abolished atrial contraction, further reducing LV preload. Left ventricular outflow tract obstruction and SAM resolved during sinus rhythm, but recurred during AJR. Haemodynamics improved with rapid volume loading, vasoconstrictor administration and continuous right ventricular pacing, thereby reducing obstruction via induced ventricular dyssynchrony. Accelerated junctional rhythm resolved spontaneously following emergence from anaesthesia, and a stable sinus rhythm was maintained. The patient was discharged on postoperative Day 12 without recurrence.

This case reports AJR as a novel trigger for suicide LV after TAVI, leading to preload reduction and promoting SAM, LVOTO, and MR. Intraoperative TOE provided clear rhythm-dependent imaging of LVOT dynamics. Vigilant rhythm monitoring and prompt, targeted haemodynamic management, including pacing to induce ventricular dyssynchrony, are crucial for prevention and treatment in predisposed patients with small, hypertrophied ventricles with a sigmoid septum.