Ultrasound localization of left ventricular outflow obstruction in hypertrophic obstructive cardiomyopathy

Shah, Pravin M.; Gramiak, Raymond; Kramer, David N.

doi:10.1016/0002-9149(69)90346-4

Cited by 63 publications

(76 citation statements)

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“…Fourteen patients were asymptomatic, two had transient symptoms of chest pain and lightheadedness, and five had moderate-to-severe symptoms (New York Heart Association functional classes IL and III) consisting primarily of functional limitation with dyspnea on exertion and fatigue. Of the 17 study patients 21 years of age or younger, 16 had either no or minimal symptoms. Only one of the 21 patients had a systolic ejection murmur (at the lower left sternal border and apex) that was as loud as grade 3/6; each of the other patients had either no murmur or a soft grade 1-2/6 murmur.…”

Section: Characterization Of Patientsmentioning

confidence: 99%

“…The electrocardiographic abnormalities in the 21 patients are summarized in table 1 +Abnormal Q or QS waves were defined as either > 4 mm in depth or > 0.04 second in duration; in 12 of these 15 patients the abnormal Q or QS waves were present in two or more leads. Ten of the 15 patients also had small Q waves (2-3 mm in depth and < 0.04 second in duration) in other leads.…”

Section: Electrocardiogramsmentioning

confidence: 99%

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Hypertrophic cardiomyopathy with unusual locations of left ventricular hypertrophy undetectable by M-mode echocardiography. Identification by wide-angle two-dimensional echocardiography.

Maron¹,

Gottdiener²,

Bonow³

et al. 1981

Circulation

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SUMMARY Twenty-one patients without evidence of hypertrophy by M-mode echocardiography were studied by wide-angle two-dimensional echocardiography to determine if they had a form of hypertrophic cardiomyopathy that could not be detected by conventional M-mode echocardiography. Each patient was suspected clinically of having hypertrophic cardiomyopathy because of a distinctly abnormal ECG and either a family history of hypertrophic cardiomyopathy or cardiac symptoms. Patients were 5-49 years old (mean 16 years) and 16 of the 21 had no functional limitation. The most common electrocardiographic abnormalities were deep Q waves, T-wave inversion and right ventricular hypertrophy. Using wide-angle two-dimensional echocardiography to reconstruct the geometry of the left ventricular wall, 16 of the 21 patients (76%) were shown to have prominent but unusually located regions of left ventricular wall hypertrophy. In each instance, the hypertrophy involved regions of the left ventricular wall through which the M-mode ultrasound beam does not usually pass, i.e., posterior ventricular septum (seven patients), anterior or lateral left ventricular free wall (seven patients) and ventricular septum near the apex (two patients). There was no echocardiographic or hemodynamic evidence of left ventricular outflow tract obstruction in any patient.Hence, some patients with hypertrophic cardiomyopathy may have substantial hypertrophy present in unusual locations of the left ventricular wall. Although electrocardiographic abnormalities suggested the presence of myocardial disease, conventional M-mode echocardiography (performed from standard parasternal positions) did not reliably identify such sites of hypertrophy, which were limited to regions of the left ventricle not accessible to the M-mode beam. Only wide-angle two-dimensional echocardiography permits definitive identification of these unusually located regions of cardiac hypertrophy and confirmation of the diagnosis of hypertrophic cardiomyopathy.HYPERTROPHIC CARDIOMYOPATHY is a disease of cardiac muscle in which the most consistent anatomic feature is a hypertrophied, nondilated left ventricle.' M-mode (one-dimensional) echocardiography is useful for identifying asymmetric septal hypertrophy,2 10 the characteristic gross anatomic feature of hypertrophic cardiomyopathy. However, we recently evaluated several patients in whom the diagnosis of hypertrophic cardiomyopathy was suspected clinically (primarily because of a distinctly abnormal ECG and a family history of hypertrophic cardiomyopathy), but conventional M-mode echocardiography did not show left ventricular hypertrophy. Such patients present the diagnostic problem of whether they have a form of hypertrophic cardiomyopathy that cannot be detected by M-mode echocardiography. Because wide-angle two-dimensional echocardiography affords visualization of portions of the left ventricular wall inaccessible to the Mmode ultrasound beam, we studied patients using thatFrom the Cardiology Branch,

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Section: Characterization Of Patientsmentioning

confidence: 99%

Section: Electrocardiogramsmentioning

confidence: 99%

Hypertrophic cardiomyopathy with unusual locations of left ventricular hypertrophy undetectable by M-mode echocardiography. Identification by wide-angle two-dimensional echocardiography.

Maron¹,

Gottdiener²,

Bonow³

et al. 1981

Circulation

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“…Others have observed this connection."' 12,[21][22][23]32 Both the coincidence that idiopathic hypertrophic subaortic stenosis is relatively less common in the young while DMSS is rare in older patients, as well as the presence of a related family history of LV obstruction in both entities lend support to this hypothesis. A relationship between discrete and diffuse LV outflow obstruction is also suggested by occasional patients who have coexisting discrete as well as diffuse (type II) obstruction.22 It seems likely that the variants of subaortic LV obstruction are interrelated, with DMSS generally being on the mild end of the spectrum, type II22 obstruction possibly being intermediate in extent and severity of outflow obstruction, and tunnel or tubular narrowing being most severe and extensive, and also being most intractable to management.12' 22, 41 Although we have raised the question that DMSS may evolve with age into more extensive variants of subaortic obstruction by citing the age-related disparity in the incidence of DMSS, additional documentation and studies to clarify this are clearly needed.…”

Section: Discussionmentioning

confidence: 95%

Discrete membranous subaortic stenosis. Report of 31 patients, review of the literature, and delineation of management.

1977

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The presentation, management, and follow-up of 31 patients with discrete membranous subaortic stenosis (DMSS) is presented. DMSS comprised 16% of 185 patients with congenital left ventricular (LV) obstruction. Only one patient was older than 40 years. The rarity of DMSS in older patients in both our population and in the literature is noted, and possible explanations are discussed. One-quarter of these patients had dyspnea, chest pain, or syncope combined with electrocardiographic left ventricular hypertrophy (LVH) and strain, and these all had peak LV outflow gradients (PSG) greater than 85 mm Hg. One-quarter had neither symptoms nor electrocardiographic abnormalities and all had PSG less than 90 mm Hg. Bacterial endocarditis was found in 13%, and in 13% an immediate family member also had congenital LV obstruction. Following surgical resection (25 patients), 18 were asymptomatic, two had residual fibromuscular obstruction, and four developed new fibromuscular obstruction after from one to six years (leading in one to late sudden death). Thus, even after resection, these patients require continued re-evaluation for residual or new LV obstruction.

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“…With M-mode echocardiography, it was possible to demonstrate that the flow impedance, rather than caused by muscular constriction, was due to the contact of the anterior leaflet of the mitral valve with the septum during mesosystole, which was longer in patients with more severe obstruction. Otherwise, the contact of the anterior leaflet of the mitral valve with the septum during mesosystole, which was more prolonged in higher obstruction, was a possible cause 14 .…”

Section: Introductionmentioning

confidence: 99%

O diagnóstico da obstrução da via de saída do ventrículo esquerdo na cardiomiopatia hipertrófica

Mattos¹,

Torres²,

Rebelatto³

et al. 2012

Arq. Bras. Cardiol.

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Hypertrophic cardiomyopathy is a prevalent genetic disease characterized by left ventricular hypertrophy, presenting dynamic obstruction of outflow tract with subaortic gradient happening at rest in 30% of the cases. It is attributed to the intricate interaction between the anterior mitral leaflet, the interventricular septum and altered flow vectors generated in left ventricle along with changes in outflow tract geometry. Mitral regurgitation in varying degrees is found with or without association with structural deformities of the valve apparatus. The exercise echocardiogram evidences latent obstruction easily induced by exercise in 60 to 75% of nonobstructive forms. The determination of the gradient under this condition must be considered in routine investigation of patients with mild or no obstruction at rest. The evaluation of hypertrophic cardiomyopathy incorporates methods based on the ultrasound image, which, along with MRI, allow recognizing ventricular obstruction generating mechanisms, thus facilitating the diagnosis and management of obstructive and latent obstructive forms.

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Ultrasound localization of left ventricular outflow obstruction in hypertrophic obstructive cardiomyopathy

Cited by 63 publications

References 0 publications

Hypertrophic cardiomyopathy with unusual locations of left ventricular hypertrophy undetectable by M-mode echocardiography. Identification by wide-angle two-dimensional echocardiography.

Hypertrophic cardiomyopathy with unusual locations of left ventricular hypertrophy undetectable by M-mode echocardiography. Identification by wide-angle two-dimensional echocardiography.

Discrete membranous subaortic stenosis. Report of 31 patients, review of the literature, and delineation of management.

O diagnóstico da obstrução da via de saída do ventrículo esquerdo na cardiomiopatia hipertrófica

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