Dynamic obstruction to left ventricular outflow: The case for its existence in hypertrophic cardiomyopathy

  • Barry J. Maron
  • S. E. Epstein
Conference paper


Obstruction to left ventricular outflow is a feature of hypertrophic cardiomyopathy (HCM) that has been of great interest to clinicians and students of this disease for over 25 years, and while generally regarded as a prominent and important component of HCM, its clinical and pathophysiologic significance has been the source of periodic and often intense disagreement and controversy (1–20). In the early 1960s, a number of investigators observed that those patients with HCM and a loud systolic heart murmur had markedly increased systolic pressure and a pressure gradient recorded within the left ventricle at cardiac catheterization (5, 21–23). This subaortic gradient could easily be distinguished from gradients artifactually produced by physical entrapment of the catheter between left ventricular trabeculations (3–5). It was therefore concluded that true obstruction to left ventricular outflow existed in these patients with HCM.


Mitral Valve Hypertrophic Cardiomyopathy Left Ventricular Outflow Tract Dynamic Obstruction Systolic Anterior Motion 
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  1. 1.
    Hernandez RR, Greenfield JC, McCall BW (1964) Pressure-flow studies in hypertrophic sub-aortic stenosis. J Clin Invest 43: 401–407PubMedCrossRefGoogle Scholar
  2. 2.
    Criley JM, Lewis KB, White RI, Ross RS (1965) Pressure gradients without obstruction: A new concept of “Hypertrophic subaortic stenosis”. Circulation 32: 881–887Google Scholar
  3. 3.
    Ross J Jr, Braunwald E, Gault JH, Mason DT, Morrow AG (1966) Mechanism of the intraventricular pressure gradient in idiopathic hypertrophic subaortic stenosis. Circulation 34: 558578Google Scholar
  4. 4.
    Ross J, Gault JH, Mason DT (1966) On the question of obstruction in idiopathic hypertrophic subaortic stenosis (editorial). Ann Int Med 65: 859–861PubMedGoogle Scholar
  5. 5.
    Wigle ED, Marquis Y, Auger P (1967) Muscular subaortic stenosis. Initial left ventricular inflow tract pressure in the assessment of intraventricular pressure differences in man. Circulation 35: 1100–1117Google Scholar
  6. 6.
    Wilson WS, Criley JM, Ross RS (1967) Dynamics of left ventricular emptying in hypertrophic subaortic stenosis: a cineangiographic and hemodynamic study. Am Heart J 73: 4–16PubMedCrossRefGoogle Scholar
  7. 7.
    Murgo JP, Alter BR, Dorethy JF, Altobelli SA, McGranahan GM (1980) Dynamics of left ventricular ejection in obstructive and nonobstructive hypertrophic cardiomyopathy. J Clin Invest 66: 1369–1382PubMedCrossRefGoogle Scholar
  8. 8.
    Goodwin JF (1982) The frontiers of cardiomyopathy. Br Heart J 48: 1–18PubMedCrossRefGoogle Scholar
  9. 9.
    Murgo JP (1982) Does outflow tract obstruction exist in hypertrophie cardiomyopathy? N Engl J Med 307: 1008–1009PubMedCrossRefGoogle Scholar
  10. 10.
    Pollick C, Morgan CD, Gilbert BW, Rakowski H, Wigle ED (1982) Muscular subaortic stenosis. The temporal relationship between systolic anterior motion of the anterior mitral leaflet and the pressure gradient. Circulation 66: 1087–1094Google Scholar
  11. 11.
    Sugrue DD, McKenna WJ, Dickie S, Myers MJ, Lavender JP, Oakley CM, Goodwin JF (1984) Relation between left ventricular gradient and relative stroke volume ejected in early and late systole in hypertrophic cardiomyopathy. Assessment with radionuclide cineangiography. Br Heart J 52: 602–609Google Scholar
  12. 12.
    Pollick C, Rakowski H, Wigle ED (1984) Muscular subaortic stenosis: the quantitative relationship between systolic anterior motion and the pressure gradient. Circulation 69: 43–49PubMedCrossRefGoogle Scholar
  13. 13.
    Gardin JM, Debestani A, Glasgow GA, Butman S, Burn CS, Henry WL (1985) Echocardiographic and Doppler flow observations in obstructed and nonobstructed hypertrophic cardiomyopathy Am I Cardiol 56: 614–621Google Scholar
  14. 14.
    Levine RA, Weyman AE (1985) Dynamic subaortic obstruction in hypertrophic cardiomyopathy: criteria and controversy (editorial). J Am Coll Cardiol 6: 16–18CrossRefGoogle Scholar
  15. 15.
    Maron BJ, Gottdiener JS, Arce J, Rosing DR, Wesley YE, Epstein SE (1985) Dynamic subaortic obstruction in hypertrophic cardiomyopathy: Analysis by pulsed Doppler echocardiography. J Am Coll Cardiol 6: 1–15Google Scholar
  16. 16.
    Siegel RJ, Criley JM (1985) Comparison of ventricular emptying with and without a pressure gradient in patients with hypertrophic cardomyopathy. Br Heart J 53: 283–291PubMedCrossRefGoogle Scholar
  17. 17.
    Criley JM, Siegel RJ: (1985) Has “obstruction” hindered our understanding of hypertrophie cardiomyopathy? (editorial) Circulation 72: 1148–1154Google Scholar
  18. 18.
    Grose R, Strain J, Spindola-Franco H (1986) Angiographie and hemodynamic correlations in patients with hypertrophie cardiomyopathy and intracavity pressure gradients. Am J Cardiol 58: 1085–1092PubMedCrossRefGoogle Scholar
  19. 19.
    Yock PG, Hatle L, Popp RL (1986) Patterns and timing of Doppler-detected intracavitary and aortic flow in hypertrophie cardiomyopathy. J Am Coll Cardiol 8: 1047–1058PubMedCrossRefGoogle Scholar
  20. 20.
    Maron BJ, Epstein SE (1986) Clinical significance and therapeutic implications of the left ventricular outflow tract pressure gradient in hypertrophie cardiomyopathy. Am J Cardiol 58: 1093–1096PubMedCrossRefGoogle Scholar
  21. 21.
    Braunwald E, Lambrew CT, Rockoff SD, Ross J Jr, Morrow AG (1964) Idiopathic hypertrophic subaortic stenosis. I. A description of the disease based upon an analysis of 64 patients. Circulation 30, suppl IV: IV-2–119Google Scholar
  22. 22.
    Epstein SE, Henry WL, Clark CE, Roberts WC, Maron BJ, Ferrans VJ, Redwood DR, Morrow AG (1974) Asymmetric septal hypertrophy. Ann lnt Med 81: 650–680Google Scholar
  23. 23.
    Wigle ED, Sasson Z, Henderson MA, Ruddy TD, Fulop J, Rakowski H, Williams WG (1985) Hypertrophic cardiomyopathy. The importance of the site and the extent of hypertrophy. A review. Prog Cardiovasc Dis 28: 1–83Google Scholar
  24. 24.
    Shabetai R (1983) Cardiomyopathy: How far have we come in 25 years, how far yet to go? J Am Coll Cardiol I: 252–263Google Scholar
  25. 25.
    Pierce GE, Morrow AG, Braunwald E (1964) Idiopathic hypertrophic subaortic stenosis. III. Intraoperative studies of the mechanism of obstruction and its hemodynamic consequences. Circulation 30, supp IV: IV-152–207Google Scholar
  26. 26.
    Jenni R, Ruffman A, Vieli M, Anliker M, Krayenbuehl HP (1985) Dynamics of aortic flow in hypertrophic cardiomyopathy. Eur Heart J 6; 391–398PubMedGoogle Scholar
  27. 27.
    Maron BJ, McIntosh CL, Seipp HW (1985) Evidence favoring existence of true subaortic obstruction in hypertrophic cardiomyopathy: Intraopertaive aortic flow studies before and after operation (abstract). Circulation 72, suppl III: III - 447Google Scholar
  28. 28.
    Gerke J, Goodwin JF (1978) The significance of systolic anterior motion ( SAM) on the mitral echo pattern in hypertrophic cardiomyopathy. Clin Cardiol 1: 152–162Google Scholar
  29. 29.
    Maron BJ, Nichols PF, Pickle LW, Wesley YE, Mulvihill JJ (1984) Patterns of inheritance in hypertrophic cardiomyopathy: Assessment by M-mode and two-dimensional echocardiography. Am J Cardiol 53: 1087–1094Google Scholar
  30. 30.
    Joyner CR, Harrison FS, Gruber JW (1971) Diagnosis of hypertrophie subaortic stenosis with a Doppler velocity detector. Ann Int Med 74: 692–696PubMedGoogle Scholar
  31. 31.
    Boughner DR, Schuld RL, Persaud JA (1975) Hypertrophie obstructive cardiomyopathy. Assessment by echocardiographic and Doppler ultrasound techniques. Br Heart J 37: 917–923Google Scholar
  32. 32.
    Morgan CD, Pollick C, Wigle ED (1979) Cineangiographic timing of left ventricular outflow obstruction and systolic emptying in muscular subaortic stenosis (abstract). Circulation 60. suppl II: II - 262Google Scholar
  33. 33.
    Glasgow GA, Gardin JM, Burn CS, Childs WH, Henry WL (1980) Echocardiographic and Doppler flow observations in idiopathic hypertrophie subaortic stenosis (IHSS) (abstract). Circulation 62, suppl III: III - 99.Google Scholar
  34. 34.
    Bonow RO, Ostrow HG, Rosing DR, Cannon MB, Leon RM, Watson SL, Bacharach MV. Green SE (1984) Dynamic pressure-volume alterations during left ventricular ejection in hypertrophie cardiomyopathy: Evidence for true obstruction to left ventricular outflow (abstract). Circulation 70, suppl II: II-17Google Scholar
  35. 35.
    Hoit B, Sahn DJ, Dalton N, Smith SC, Yun Y, Dittrich H (1985) Color Doppler flow mapping studies of jet formation in hypertrophie cardiomyopathy (abstract). Circulation 72, suppl III: III - 447Google Scholar
  36. 36.
    Stewart WJ, Schiavone WA, Salcedo EE, Lever HM, Cosgrove DM, Gill CC (1985) Intraoperative Doppler velocity correlates with outflow gradient in HOCM pre and post myectomy (abstract). Circulation 72, suppl III: III - 447Google Scholar
  37. 37.
    Bryg J, Labovitz AJ, Williams GA, Kennedy HL (1986) Systolic anterior motion of the mitral valve is temporally related to peak pressure gradient in hypertrophie obstructive cardiomyopathy. (abstract) J Am Coll Cardiol 7: 138AGoogle Scholar
  38. 38.
    Henry WL, Calrk CE, Gancy DL, Epstein SE (1973) Echocardiographic measurement of the left ventricular outflow gradient in idiopathic hypertrophie subaortic stenosis. N Eng J Med 288: 989–993CrossRefGoogle Scholar
  39. 39.
    Shah PM, Taylor RD, Wong M (1981) Abnormal mitral valve coaptation in hypertrophie obstructive cardiomyopathy: proposed role in systolic anterior motion of mitral valve. Am J Cardiol 48: 258–262PubMedCrossRefGoogle Scholar
  40. 40.
    Shah PM, Gramiak R, Kramer DH (1969) Ultrasound location of left ventricular outflow obstruction in hypertrophie obstructive cardiomyopathy. Circulation 40: 3–11PubMedGoogle Scholar
  41. 41.
    Spirito P, Maron BJ, Rosing DR (1984) Morphologic determinants of hemodynamic state following ventricular septal myotomy-myectomy in patients with hypertrophie cardiomyopathy: M-mode and two-dimensional echocardiographic assessment. Circulation 70: 984–995Google Scholar
  42. 42.
    Spirito P, Maron BJ (1984) Patterns of systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy: assessment by two-dimensional echocardiography. Am J Cardiol 54: 1039–1046PubMedCrossRefGoogle Scholar
  43. 43.
    Shah PM, Gramiak R, Adelman AG, Wigle ED (1972) Echocardiographic assessment of the effects of surgery and propranolol on the dynamics of outflow obstruction in hypertrophic sub-aortic stenosis. Circulation 45: 516–521PubMedGoogle Scholar
  44. 44.
    Popp R, Harrison D (1969) Ultrasound in the diagnosis and evaluation of therapy of idiopathic hypertrophic subaortic stenosis. Circulation 40: 905–914Google Scholar
  45. 45.
    Wigle ED, Adelman AG, Silver MD (1971) Pathophysiological considerations in muscular sub-aortic stenosis. In: Wolstenholme GEW and O’Connor M (eds) Hypertrophic obstructive cardiomyopathy. CIBA-Foundation Study Group Monograph 37, London, J & A Churchill, pp 6375Google Scholar
  46. 46.
    Henry WL, Clark CE, Griffith JM, Epstein SE (1975) Mechanism of left ventricular outflow obstruction in patients with obstructive asymmetric septal hypertrophy (idiopathic hypertrophie subaortic stenosis). Am J Cardiol 35: 337–345PubMedCrossRefGoogle Scholar
  47. 47.
    Gilbert BW, Pollick C, Adelman AG, Wigle ED (1980) Hypertrophic cardiomyopathy: Subclassification by M-mode echocardiography. Am J Cardiol 45: 861–872Google Scholar
  48. 48.
    Wigle ED, Adelman AG, Auger P, Marquis Y (1969) Mitral regurgitation in muscular subaortic stenosis. Am J Cardiol 24: 698–706PubMedCrossRefGoogle Scholar
  49. 49.
    Kinoshita N, Nimura Y, Okamoto M, Miyatake K, Nagata S, Sakakibara H (1983) Mitral regurgitation in hypertrophic cardiomyopathy. Noninvasive study by two-dimensional Doppler echocardiography. Br Heart J 49: 574–583Google Scholar
  50. 50.
    Eslami B, Aryanpur I, Tabaeezadeh M, Alipour M, Nazarian I, Shakibi JG (1979) Midventricular obstruction. Jap Heart J 20: 117–126PubMedCrossRefGoogle Scholar
  51. 51.
    Falicov RE, Resnekov L (1977) Mid-ventricular obstruction in hypertrophic obstructive cardiomyopathy. New diagnostic and therapeutic challenge. Br Heart J 39: 701–705Google Scholar
  52. 52.
    Grose R, Maskin C, Spindola-Franco H, Yipintsoi T (1981) Production of left ventricular cavitary obliteration in normal man. Circulation 64: 448–455PubMedCrossRefGoogle Scholar
  53. 53.
    Wigle ED, Auger P, Marquis Y (1967) Muscular subaortic stenosis. The direct relation between the intraventricular pressure difference and the left ventricular ejection time. Circulation 36: 36–44Google Scholar
  54. 54.
    Gault JH, Ross J Jr, Mason DT (1966) Patterns of brachial arterial blood flow in conscious human subjects with and without cardiac dysfunction. Circulation 34: 833–848PubMedGoogle Scholar
  55. 55.
    Louie EK, Maron BJ, Greene KJ (1986) Variations in flow-velocity waveforms obtained by pulsed Doppler echocardiography in the normal human aorta. Am J Cardiol 58: 821–826PubMedCrossRefGoogle Scholar
  56. 56.
    Spirito P, Maron BJ (1983) Significance of left ventricular outflow tract cross-sectional area in hypertrophic cardiomyopathy: A two-dimensional echocardiographic assessment. Circulation 67: 1100–1108Google Scholar
  57. 57.
    Cannon RO, Leon MB, Rosing DR, Epstein SE (1985) Comparison of coronary flow and myocardial metabolism at rest and during pacing-induced ischemia between patients with obstructive and non-obstructive hypertrophic cardiomyopathy (abstract). Circulation 72, suppl III: III - 446Google Scholar
  58. 58.
    Wigle ED, Trimble AS, Adelman AG, Bigelow WG (1968) Surgery in muscular subaortic stenosis. Prog Cardiovasc Dis 11: 83–112PubMedCrossRefGoogle Scholar
  59. 59.
    Bigelow WG, Trimble AS, Wigle ED, Adelman AG, Felderhof CH (1974) The treatment of muscular subaortic stenosis. J Thorac Cardiovasc Surg 68: 384–392PubMedGoogle Scholar
  60. 60.
    Bolton MR, King JF, Polumbo RA, Mason DT, Pugh DM, Reis RL, Dunn MI (1974) The effects of operation on the echocardiographic features of idiopathic hypertrophic subaortic stenosis. Circulation 50: 897–900PubMedGoogle Scholar
  61. 61.
    Morrow AG, Reitz BA, Epstein SE, Henry WL, Conkle DM, Itscoitz SB, Redwood DR (1975) Operative treatment in hypertrophic subaortic stenosis: Techniques, and the results of pre and assessment in 83 patients. Circulation 52: 88–102PubMedGoogle Scholar
  62. 62.
    Reis RL, Hannah H, Carley JE, Pugh DM (1977) Surgical treatment of idiopathic hypertrophic subaortic stenosis (IHSS). Postoperative results in 30 patients following ventricular septal myotomy and myectomy (Morrow procedure). Circulation 56, suppl II: II-128–132Google Scholar
  63. 63.
    Agnew TM, Barratt-Boyes BC, Brandt PWT, Roche AHG, Lowe JB, O’Brien KG (1977) Surgical resection in idiopathic hypertrophic subaortic stenosis with a combined approach through aorta and left ventricle. J Thorac Cardiovasc Surg 74: 307–316PubMedGoogle Scholar
  64. 64.
    Maron BJ, Merrill WH, Freier PA, Kent KM, Epstein SE, Morrow AG (1978) Long-term clinical course and symptomatic status of patients after operation for hypertrophie subaortic stenosis. Circulation 57: 1205–1213PubMedGoogle Scholar
  65. 65.
    Maron BJ, Epstein SE, Morrow AG (1983) Symptomatic status and prognosis of patients after operation for hypertrophic obstructive cardiomyopathy: Efficacy of ventricular septal myotomy and myectomy. Eur Heart J 4, Suppl F: 175–185Google Scholar
  66. 66.
    Schapira JN, Stemple DR, Martin RP, Rakowski H, Stinson EB, Popp RL (1978) Single and two-dimensional echocardiographic visualization of the effects of septal myectomy in idiopathic hypertrophic subaortic stenosis. Circulation 58: 850–860PubMedGoogle Scholar
  67. 67.
    Binet JP, David P, Piot JD (1983) Surgical treatment of hypertrophic obstructive cardiomyopathies. Eur Heart J 4, suppl F: 191–195Google Scholar
  68. 68.
    Beahrs MM, Tajik AJ, Seward JB, Giuliani ER, McGoon DC (1983) Hypertrophic obstructive cardiomyopathy: 10–21 year follow-up after partial septal myectomy. Am J Cardiol 51: 11601166Google Scholar
  69. 69.
    Bircks W, Schulte HD (1983) Surgical treatment of hypertrophie obstructive cardiomyopathy with special reference to complications and to atypical hypertrophic obstructive cardiomyopathy. Eur Heart J 4, suppl F: 187–190Google Scholar
  70. 70.
    Fighali S, Krajcer Z, Leachman RD (1984) Septal myomectomy and mitral valve replacement for idiopathic hypertrophie subaortic stenosis: short-and long-term follow-up. J Am Coll Cardiol 3: 1127–1134PubMedCrossRefGoogle Scholar
  71. 71.
    Rothlin ME, Gobet D, Haberer T, Krayenbuehl HP, Turina M, Senning A (1983) Surgical treatment versus medical treatment in hypertrophie obstructive cardiomyopathy. Eur Heart J 4, suppl F: 215–223Google Scholar
  72. 72.
    Borer JS, Bacharach SL, Green MV, Kent KM, Rosing DR, Seides SF, Morrow AG, Epstein SE (1979) Effect of septal myotomy and myectomy on left ventricular systolic function at rest and during exercise in patients with IHSS. Circulation 60, suppl I: I-82–87Google Scholar
  73. 73.
    Cannon RO, Rosing DR, McIntosh CL, Epstein SE (1985) Hypertrophic cardiomyopathy (HCM): Improved hemodynamics, metabolism, and anginal threshold following surgical relief of obstruction (abstract). Circulation 72, suppl III: III - 447Google Scholar
  74. 74.
    Redwood DR, Goldstein RE, Hirshfeld J, Borer JS, Morganroth J, Morrow AG, Epstein SE (1979) Exercise performance after septal myotomy and myectomy in patients with obstructive hypertrophic cardiomyopathy. Am J Cardiol 44: 215–220PubMedCrossRefGoogle Scholar
  75. 75.
    Losse B, Kuhn H, Loogen F, Schulte HD (1983) Exercise performance in hypertrophic cardiomyopathies. Eur Heart J 4, Suppl F 197–208Google Scholar

Copyright information

© Dr. Dietrich Steinkopff Verlag GmbH & Co. KG, Darmstadt 1988

Authors and Affiliations

  • Barry J. Maron
    • 1
    • 2
  • S. E. Epstein
    • 1
  1. 1.Cardiology Branch, National Heart, Lung, and Blood InstituteNational Institutes of HealthBethesdaUSA
  2. 2.National Institutes of Health National Heart, Lung, and Blood InstituteBethesdaUSA

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