Myocardial ischemia with left ventricular outflow obstruction

We are reporting on a 32-year-old patient who had been treated for a prolonged period of time for symptoms of HOCM. However, the diagnosis of a flow acceleration and pressure gradient in the outflow tract had only been made by echocardiography (ECHO) up to that point. In 2004, a 2-chamber pacemaker with a short AV conduction time (70 ms) was implanted for a left precordial repolarization abnormality and to lower the pressure gradient between the ventricle and outflow tract. Freedom from symptoms was not actually achieved with this treatment. In February of this year, the patient was found in a non-responsive state following what had most likely been a period of complete well-being. Emergency cardiovascular resuscitation was not started immediatly, however, and the interval before resuscitation was started was approximately 5 minutes. When the emergency medical services arrived, the patient had no pulse of his own, while the pacemaker continued to work. After a short period of cardiopulmonary reanimation, a status of ventricular fibrillation was reached. At this point, a single defibrillation of 200 joules was applied and spontaneous circulation was established once again. The patient was only taking inadequate gasping breaths; as a result, he was intubated immediately. A low dose of adrenaline was administered due to hypotonic circulation; the patient then became hemodynamically stable. Upon admission to our clinic, cerebral imaging was immediately ordered; this showed no intracerebral bleeding, ischemia or edema. Neuroprotective hypothermia therapy was also immediately introduced for a period of 48 hours. Echocardiography revealed severe left ventricular hypertrophy with normal left ventricular ejection fraction (EF > 60%) and normal dimensions. Additionally, the ECHO exhibited nearly complete obstruction of the the left ventricular outflow tract (LVOT) by the hypertrophied septum including a systolic anterior motion phenomena (SAM) by the anterior leaflet of the m