Simultaneous Intracardiac Pressure Measurement to Detect the Origin of Pressure Gradient in a Patient with Coexisting Aortic Stenosis and Asymmetrical Interventricular Septal Hypertrophy

Figures

• 

  Figure 1.. Chest radiography (A) and 12-lead electrocardiogram (B) at the first patient visit. Chest radiography findings were essentially normal: cardio-thoracic ratio was 45%. Electrocardiography revealed sinus rhythm at a rate of 91 beat per minutes, but voltage criteria indicated left ventricular hypertrophy.

• 

  Figure 2.. Transthoracic echocardiography of parasternal long-axis view (A), and transesophageal echocardiography of mid-esophageal aortic valve long-axis view (B), and short-axis view (C) before the operation. Continuous-wave Doppler recorded from the LV apex with the interrogation being directed through the left ventricular tract (D, E). Transthoracic echocardiography of parasternal long-axis view after the operation (F). There was a LVOT narrowing due to asymmetrical hypertrophy of basal intraventricular septum (A, B). The AVA was calculated as 0.60 cm2 by planimetry (C). The continuous-wave Doppler recordings from the LV apex along a line oriented through the aortic valve showed a peak velocity of 4.1 m/s, maximum pressure gradient of 67.1 mmHg, and mean pressure gradient of 41.3 mmHg (D). The continuous-wave Doppler recordings in a direction slightly shifted by that in D showed dagger-shaped wave with a late systolic peak velocity of 3.0 m/s (E). After the operation, the LVOT disappeared (F). LVOT – left ventricular outflow tract; AVA – aortic valve area.

• 

  Figure 3.. Left ventriculogram in the right anterior oblique projection (A) and simultaneous pressure recordings (B).There was no apparent obstruction in the subaortic LVOT. We found peak-to-peak and maximum instantaneous pressure gradients of 45 mmHg and 80 mmHg, respectively between subaortic LVOT and Ao, and a peak-to-peak pressure gradient of 12 mmHg between subaortic LVOT and LV apex. The peak-to-peak pressure gradient during continuous isoproterenol infusion was 20 mmHg between the subaortic LVOT and the LV apex, whereas peak-to-peak and maximal instantaneous pressure gradients were 90 mmHg and 125 mmHg between the LV apex and the Ao, respectively. LVOT – left ventricular outflow tract; Ao – ascending aorta.