Man With Progressive Exertional Dyspnea.

Abstract

A 65-year-old man with a history of hypertension and left ventricular hypertrophy presented with progressive exertional dyspnea for one month. Physical examination showed a blood pressure of 155/82 mmHg, a pulse of 102 beats/min, mild icteric sclera, and a high-pitched midsystolic murmur at the left lower sternal border. Laboratory tests reported a normal hemoglobin level. Electrocardiography was typical for left ventricular hypertrophy, and chest radiography showed mild cardiomegaly without active lung infiltrate (Figure 1). Ultrasonography with the parasternal long-axis view of the heart revealed increased thickness of the interventricular septum and an obvious aortic valve fluttering when the leaflets were open (Figure 2 and Video E1). The aortic valve fluttering during the systolic phase was confirmed by the M-mode echocardiogram (Figure 3).Figure 2Ultrasonography with the parasternal long-axis view of the heart revealed increased thickness of the interventricular septum (asterisk) and an obvious aortic valve fluttering when the leaflets were open (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3The aortic valve fluttering during the systolic phase (arrows) was shown on the M-mode tracing at the aortic valve in the parasternal long-axis view of the heart.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Hypertrophic obstructive cardiomyopathy. After consultation with cardiovascular specialists, the patient received an elective left ventricular myomectomy for hypertrophic obstructive cardiomyopathy. The fluttering of the cusps of the aortic valve is mostly reported during diastole, and it is associated with flail cusps with significant aortic regurgitation.1Qamar S. Ammar K.A. Paterick T.E. et al.Diastolic fluttering of the aortic valve: pathognomonic M-mode features of flail cusp.Eur Heart J Cardiovasc Imaging. 2013; 14: 204Crossref PubMed Scopus (1) Google Scholar Systolic fluttering of the aortic valve has been reported, which was explained by turbulent systolic flow downstream of an aortic valve.2Becsek B. Pietrasanta L. Obrist D. Turbulent systolic flow downstream of a bioprosthetic aortic valve: velocity spectra, wall shear stresses, and turbulent dissipation rates.Front Physiol. 2020; 11577188Crossref PubMed Scopus (12) Google Scholar Before the widespread use of Doppler echocardiogram, systolic fluttering was used to diagnose a patient with severe aortic stenosis.3Chin M.L. Bernstein R.F. Child J.S. et al.Aortic valve systolic flutter as a screening test for severe aortic stenosis.Am J Cardiol. 1983; 51: 981-985Abstract Full Text PDF PubMed Scopus (8) Google Scholar Systolic fluttering of the aortic valve indicates a large pressure gradient during the systole, which is pathognomonic for hypertrophic obstructive cardiomyopathy.4Pollick C. Shmueli H. Maalouf N. et al.Left ventricular cavity obliteration: mechanism of the intracavitary gradient and differentiation from hypertrophic obstructive cardiomyopathy.Echocardiography. 2020; 37: 822-831Crossref PubMed Scopus (1) Google Scholar Since left ventricular hypertrophy is common in the elderly, recognizing the aortic valve fluttering by clinicians facilitates the correlation of clinical symptoms, consultation, and timely treatment for hypertrophic obstructive cardiomyopathy. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI1YzAxZjJmZDVmYjg2ZTM4ZGFjM2EwMjc4ZDUyMGQ4YiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc1NzYwNDg4fQ.l8n6GzpnK5MPpC1H1vaaZNBSV9NXyo8dNwHvQgC-HV8KCQK6B7P0Eb2wyRB1OKRFVvXIu8cVL4pTqPEIchOdRO7GgaY6-MTWE-ZZZ8wFG9AaDLZGd3SK_NVRyPuThLWyjmXP5gQXvoFcqAmT3XqT3VZVCRfD5JbkLNTd8kms7lZw2PGWPRexp3Q2d_Dw5dWL8eBCZ5NaEBEAmvhio4GuUNjVoHR7tfEV8q06Hqur4PFADzFXVcNGWW87aGJxI9HcWgK6F86W17-3k0DTUt4BPMMDatDekNdROGq9X_ekBZ_Yv53pq652T6lVJYliLhMQNt19sqJR5r6mY2rzWF6O5A Download .mp4 (2.98 MB) Help with .mp4 files Video E1Ultrasonography with the parasternal long-axis view of the heart revealed a thick interventricular septum indicating left ventricular hypertrophy. In the brightness mode, a remarkable aortic valve fluttering in the systolic phase was noted (white arrow, 00:05). Color Doppler (00:09 to 00:13) demonstrated turbulent flows originating from the left ventricular outflow tract (black arrowheads, 00:10), which was compatible with hypertrophic obstructive cardiomyopathy. (Used with permission of Nin-Chieh Hsu, Taipei City Hospital, Taiwan.)