18: A Challenging Case of Hypertrophic Obstructive Cardiomyopathy with Diffuse Alveolar Hemorrhage Managed by Veno-Venous ECMO

Introduction: Hypertrophic obstructive cardiomyopathy (HOCM) can present with pulmonary edema due to an acute increase in left ventricular outflow tract (LVOT) gradient, while severe pulmonary edema itself can be rarely complicated by diffuse alveolar hemorrhage (DAH). Veno-Venous Extracorporeal membrane oxygenation (VV-ECMO) can be utilized in severe respiratory failure secondary to DAH Case Presentation: A 37-year-old patient was admitted with hypoxic respiratory failure secondary to severe pulmonary edema which required intubation. Echocardiography (ECHO) revealed evidence of HOCM with systolic anterior motion of the mitral valve and high LVOT gradient of 100, so beta blockers were initiated. After initial improvement, he developed sudden hypoxia with P/F ratio less than 50 on maximal ventilatory support. Chest X-ray revealed bilateral dense consolidation (Figure 1), all of which prompted the initiation of VV-ECMO. Subsequent bronchoscopy confirmed the diagnosis of DAH. The patient was initiated on esmolol infusion to decrease the LVOT gradient. He quickly improved and had rapid clearance of his chest X-ray findings. The patient was subsequently weaned off VV-ECMO and discharged home. Conclusion: To our knowledge no similar cases of HOCM complicated with DAH were reported. Other reports showed cases of hemoptysis due to HOCM. The acute increase in pulmonary venous pressure due to the high gradient is hypothesized to be the culprit. The quick resolution of CXR findings in our patient with the control of the LVOT gradient supports this theory. This study underscores the feasibility of VV-ECMO in HOCM patients with respiratory failure.