PMC5926514_01
Echocardiogram showing 75 mmHg gradient in the left ventricular outflow tract with Valsalva.
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After Valsalva maneuver, the LVOT gradient increased strikingly to 75 mmHg (Figure 1) with a further increase to 81 mmHg after administration of amyl nitrite.
Cardiac MRI showing multiple heads of the posteromedial papillary muscle in the three chamber view (a), four chamber view (b), and short axis view (c), with a suggestion of an abnormal chordal attachment to the anterior mitral valve leaflet (red arrow). Delayed gadolinium imaging (d) showing no increased signal.
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There was a suggestion that the more anteriorly displaced head of the posteromedial papillary muscle had aberrant chordal attachments to the anterior mitral valve leaflet that contributed to the SAM (Figure 2).
Long axis of the LV from a deep transgastric view using transesophageal echocardiography. LV = left ventricle, PM = posterior papillary muscle, and Ao = aorta. During midsystole, there is anterior motion of the apically displaced posterior papillary muscle (red arrow).
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A subsequent transesophageal echocardiogram (TEE) demonstrated the mobile anteriorly displaced posterior papillary muscle with SAM (Figure 3).