Subaortic Membrane Co-existing With Hypertrophic Cardiomyopathy: A Clinically Challenging Diagnosis

Figure 1. ECG of the patient shows sinus rhythm with T-wave Inversion in I, aVL, and V5-6.

Figure 2. PLAX and APLAX view 2-D imaging showing severe LVH, septum is relatively thicker as compared to posterior wall (ASH). There is a sub-valvular membrane. Figure 2 (Left): 2-D PLAX in a diastolic frame (as the mitral valve is slightly open) showing severe LVH. The septum is relatively thicker as compared to posterior wall. Arrows pointing towards sub-aortic membrane. Figure 2 (Right): 2-D APLAX (three chamber) view in a systolic frame (as the mitral valve is closed and the aortic valve is slightly open). Arrows pointing towards echo dense sub-aortic valve membrane. PLAX=parasternal long axis; APLAX: apical long axis; 2-D: two-dimensional; LVH=left ventricular hypertrophy; ASH=asymmetric septal hypertrophy; LV=left ventricle; LA=left atrium; AO=aorta

Figure 3. AP5CH view with color Doppler and spectral Doppler image. There is severe LVOT obstruction with peak velocity 5.68m/sec, peak gradient 129mmHg, and mean gradient 79mmHg.There is also spectral Doppler evidence of AR. AP5CH: apical five chamber; LVOT=left ventricular outflow tract; AR=aortic regurgitation

Figure 4. PLAX view showing systolic anterior motion of MV on 2-D image and turbulent flow in LVOT on color Doppler. To accurately identify the systolic anterior motion of the MV, an ECG is performed with the echo to time the events. However, in this case, an ECG is not available. PLAX=parasternal long axis; MV=mitral valve; LVOT=left ventricular outflow tract

Figure 5. AP5CH view with color Doppler and spectral Doppler image There is double envelope of LVOT flow showing high flow velocities and gradients of dynamic and fixed components. Dynamic peak velocity 2.97m/sec and peak gradient 35mmHg. AP5CH: apical five chamber; LVOT=left ventricular outflow tract