Post-TAVI Hypotension as a Diagnostic and Therapeutic Challenge: A Case Report of Delayed-Onset Suicide Left Ventricle

Background: Transcatheter aortic valve implantation (TAVI) for severe aortic stenosis leads to haemodynamic improvement. Patients with a small, hypertrophic left ventricle are predisposed to dynamic left ventricular outflow tract obstruction (LVOTO). Abrupt afterload reduction may trigger “suicide left ventricle”, characterised by hypercontractility, near-complete cavity obliteration, systolic anterior motion (SAM)-related LVOTO, and hypotension. Early recognition is crucial because treatments may aggravate the obstruction. Case presentation: A 78-year-old man with hypertension, dyslipidaemia, severe calcific tricuspid aortic stenosis, LV hypertrophy, small LV cavity, and bifascicular block underwent pre-TAVI evaluation. Coronary angiography excluded obstructive coronary disease; because of recurrent syncope, a dual-chamber pacemaker was implanted before TAVI. After transfemoral implantation of a 29 mm Medtronic Evolut FX+ bioprosthesis, the patient developed dyspnoea and hypotension. Bleeding, arrhythmias, and cardiac tamponade were excluded, and no evidence of an acute structural prosthetic complication was identified. Echocardiography showed SAM, a hyperdynamic LV with near-complete systolic cavity obliteration, and a 106 mmHg LVOT gradient with a “dagger-shaped” profile. Intravenous fluid administration, avoidance of diuretics, esmolol, and pacemaker reprogramming were followed by haemodynamic stabilisation and a reduction in LVOTO. Conclusions: Suicide left ventricle is a rare cause of post-TAVI hypotension; male sex and delayed haemodynamic instability were atypical. Early echocardiographic recognition, post-procedural monitoring, and pathophysiology-driven management were paramount for preventing progression to shock.