Background: Aortic stenosis is narrowing of the aortic valve opening, leading to a reduced amount of blood leaving the left ventricle. Transcatheter Aortic Valve Replacement (TAVR) is an option for patients who are poor candidates for Surgical Aortic Valve Replacement. 

Case Presentation: An 80-year-old lady presented for dyspnea. She had a history of congestive heart failure, chronic obstructive pulmonary disease (Stage II), type II diabetes mellitus, hypertension, hypercholesterolemia, and polymyalgia rheumatica. Physical examination revealed a grade 3 systolic murmur in the aortic area. Echocardiography showed a preserved ejection fraction with heavily calcified aortic cusps and moderate to severe stenosis with a mean gradient of 36.4mmHg and a valve area of 1.1sqcm. 

Patient underwent an uneventful TAVR. Post procedure she manifested with refractory hypotension and supraventricular tachycardia. She was treated with adenosine and normal saline and started on norepinephrine and dopamine. She continued to decline and was intubated and put on the ventilator, she remained hypoxemic, requiring an FIO2 of 100% and PEEP of 14 to achieve saturations in the mid-’80% range. Chest x-ray showed pulmonary edema. She was started on furosemide. Repeat bedside echo showed a well-positioned and functioning aortic valve with a hyperdynamic collapsed left ventricle despite 3 L normal saline. We made a diagnosis of suicide left ventricle post TAVR, and discontinued inotropic agents and started on metoprolol and phenylephrine. Over the next couple of hours, repeat echocardiogram showed improved left ventricular cavity size with hemodynamic and respiratory improvement. However, she remained unresponsive, and an MRI showed large bilateral acute strokes. 

Final Diagnosis: Suicide Left Ventricle 

Discussion and Management: The patient presented above manifested with a suicide left ventricle. This develops following removal of the fixed obstruction in the aortic outflow tract when there can be development of dynamic left ventricular outflow tract obstruction due to abrupt reduction in afterload to a stenotic aortic valve. An echocardiogram post TAVR showing a small left ventricular cavity with a relatively normal or increased ejection fraction should raise the suspicion of a suicide left ventricle which presents with Circulatory collapse. Recognition of this phenomenon is challenging and treatment involves increasing afterload, reducing heart rate and pacing in the setting of conduction abnormalities. Other modalities like ECMO and LVAD support may be helpful if available.