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Provokable left ventricular outflow tract obstruction in a patient without hypertrophy

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Abstract

Background. A 61-year-old man presented with shortness of breath and chest pain on exertion. He had been diagnosed as having hiatus hernia 2 years previously and was taking proton-pump inhibitors as necessary. He had a family history of ischemic heart disease and subarachnoid hemorrhage.

Investigations. Physical examination, electrocardiography, echocardiography, cardiopulmonary exercise testing, coronary angiography, transoesophageal echocardiography, stress echocardiography.

Diagnosis. Provokable left ventricular outflow tract obstruction without electrocardiographic abnormalities or left ventricular hypertrophy on echocardiography.

Management. Pharmacological therapy (atenolol 50 mg daily, disopyramide 250 mg twice daily), dual-chamber pacemaker implantation.

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Figure 1: Resting electrocardiography on presentation.
Figure 2: Echocardiography performed during an upright bicycle stress test with patient off medication showing flow acceleration in the left ventricular outflow tract and the gradient on continuous wave Doppler monitoring.

References

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Acknowledgements

Written consent for publication was obtained from the patient.

Author information

Authors and Affiliations

  1. The Heart Hospital, London, UK

    Ferdinando Pasquale

  2. The Heart Hospital and Great Ormond Street Hospital, London, UK

    Maria Teresa Tomé-Esteban

  3. Tor Vergata Hospital, Rome, Italy

    Riccardo Morgagni

  4. The Heart Hospital and The Institute of Child Health, Great Ormond Street Hospital, London, UK

    Perry Elliott

Authors
  1. Ferdinando Pasquale
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  2. Maria Teresa Tomé-Esteban
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  3. Riccardo Morgagni
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  4. Perry Elliott
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Corresponding author

Correspondence to Perry Elliott.

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Competing interests

The authors declare no competing financial interests.

Supplementary information

Supplementary movie

Resting echocardiogram on presentation. This loop shows the angulated shape of the septum at parasternal long-axis view. In spite of the normal thickness, the septum protrudes in the left ventricular outflow tract causing a mechanical narrowing. Furthermore it is possible to appreciate the elongated anterior mitral leaflet and the absence of systolic anterior motion at rest. (AVI 8896 kb)

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Pasquale, F., Tomé-Esteban, M., Morgagni, R. et al. Provokable left ventricular outflow tract obstruction in a patient without hypertrophy. Nat Rev Cardiol 6, 313–316 (2009). https://doi.org/10.1038/nrcardio.2009.7

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  • DOI: https://doi.org/10.1038/nrcardio.2009.7

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