PMC5067769_01
Upper panels show 2D-echocardiographic transthoracic parasternal long axis views in diastole (yellow arrow) along with narrow LVOT and turbulent jet (red arrows) in early systole. Left lower panel shows a mean trans-mitral diastolic gradient of 22 mmHg. Right lower panel shows peak velocity of 5.1 m/s across the LVOT.
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On Doppler examination, mean trans-mitral diastolic gradient was 22 mmHg, and peak systolic gradient was 244 mmHg (Fig. 1).
Upper panels show LVOT in parasternal long axis views. Yellow hollow arrow points toward the membrane. The lower panels show the shape and the size of the LVOT during systole in 3D reconstruction (left lower, yellow solid arrows) and two levels of obstruction in tandem in LVOT (right lower image, red arrow and yellow arrow). Persistent non-closure of the mitral orifice (MVO) during systole is due to the flail leaflet.
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Careful examination of the LVOT revealed a membrane attached to the ventricular surface of the bioprosthetic strut and the left side of the interventricular septum (Fig. 2, Fig. 3).
PMC5067769_02
Trans-thoracic 2D echocardiographic parasternal long axis view focusing on the LVOT. Note narrow LVOT with color flow turbulence during systole in upper two images. The lower left image in short axis shows abnormally placed bioprosthetic strut juxtaposed to localized thickening of the anterior interventricular septum (red arrows). Right lower image shows spectrum of systolic and diastolic flow across the LVOT with a peak gradient of 65 mmHg on continuous-Doppler examination.
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Trans-thoracic echocardiogram revealed thickened left ventricular walls, anteriorly oriented mitral prosthesis projecting into the LVOT, which showed flow turbulence during systole on color Doppler examination (Fig. 4).
2D echocardiographic parasternal long axis views showing narrow LVOT (red arrow) both during systole and diastole due to abnormally projecting bioprosthetic strut. Note markedly thickened anterior interventricular septum. The bioprosthetic leaflets show normal mobility.
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Multiple views showed localized thickening of the anterior interventricular septum at the contact point of the strut during systole (Fig. 5).