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

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New Aspects of Hypertrophic Cardiomyopathy

Abstract

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.

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References

  1. Hernandez RR, Greenfield JC, McCall BW (1964) Pressure-flow studies in hypertrophic sub-aortic stenosis. J Clin Invest 43: 401–407

    Article  PubMed  CAS  Google Scholar 

  2. Criley JM, Lewis KB, White RI, Ross RS (1965) Pressure gradients without obstruction: A new concept of “Hypertrophic subaortic stenosis”. Circulation 32: 881–887

    Google Scholar 

  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: 558578

    Google Scholar 

  4. Ross J, Gault JH, Mason DT (1966) On the question of obstruction in idiopathic hypertrophic subaortic stenosis (editorial). Ann Int Med 65: 859–861

    PubMed  Google Scholar 

  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: 1100–1117

    Google Scholar 

  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: 4–16

    Article  PubMed  CAS  Google Scholar 

  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: 1369–1382

    Article  PubMed  CAS  Google Scholar 

  8. Goodwin JF (1982) The frontiers of cardiomyopathy. Br Heart J 48: 1–18

    Article  PubMed  CAS  Google Scholar 

  9. Murgo JP (1982) Does outflow tract obstruction exist in hypertrophie cardiomyopathy? N Engl J Med 307: 1008–1009

    Article  PubMed  CAS  Google Scholar 

  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: 1087–1094

    Google Scholar 

  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: 602–609

    Google Scholar 

  12. Pollick C, Rakowski H, Wigle ED (1984) Muscular subaortic stenosis: the quantitative relationship between systolic anterior motion and the pressure gradient. Circulation 69: 43–49

    Article  PubMed  CAS  Google Scholar 

  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: 614–621

    CAS  Google Scholar 

  14. Levine RA, Weyman AE (1985) Dynamic subaortic obstruction in hypertrophic cardiomyopathy: criteria and controversy (editorial). J Am Coll Cardiol 6: 16–18

    Article  Google Scholar 

  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: 1–15

    Google Scholar 

  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: 283–291

    Article  PubMed  CAS  Google Scholar 

  17. Criley JM, Siegel RJ: (1985) Has “obstruction” hindered our understanding of hypertrophie cardiomyopathy? (editorial) Circulation 72: 1148–1154

    CAS  Google Scholar 

  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: 1085–1092

    Article  PubMed  CAS  Google Scholar 

  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: 1047–1058

    Article  PubMed  CAS  Google Scholar 

  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: 1093–1096

    Article  PubMed  CAS  Google Scholar 

  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-2–119

    Google Scholar 

  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: 650–680

    Google Scholar 

  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: 1–83

    Google Scholar 

  24. Shabetai R (1983) Cardiomyopathy: How far have we come in 25 years, how far yet to go? J Am Coll Cardiol I: 252–263

    Google Scholar 

  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-152–207

    Google Scholar 

  26. Jenni R, Ruffman A, Vieli M, Anliker M, Krayenbuehl HP (1985) Dynamics of aortic flow in hypertrophic cardiomyopathy. Eur Heart J 6; 391–398

    PubMed  CAS  Google Scholar 

  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 - 447

    Google Scholar 

  28. Gerke J, Goodwin JF (1978) The significance of systolic anterior motion ( SAM) on the mitral echo pattern in hypertrophic cardiomyopathy. Clin Cardiol 1: 152–162

    Google Scholar 

  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: 1087–1094

    Google Scholar 

  30. Joyner CR, Harrison FS, Gruber JW (1971) Diagnosis of hypertrophie subaortic stenosis with a Doppler velocity detector. Ann Int Med 74: 692–696

    PubMed  CAS  Google Scholar 

  31. Boughner DR, Schuld RL, Persaud JA (1975) Hypertrophie obstructive cardiomyopathy. Assessment by echocardiographic and Doppler ultrasound techniques. Br Heart J 37: 917–923

    Google Scholar 

  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 - 262

    Google Scholar 

  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. 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-17

    Google Scholar 

  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 - 447

    Google Scholar 

  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 - 447

    Google Scholar 

  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: 138A

    Google Scholar 

  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: 989–993

    Article  CAS  Google Scholar 

  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: 258–262

    Article  PubMed  CAS  Google Scholar 

  40. Shah PM, Gramiak R, Kramer DH (1969) Ultrasound location of left ventricular outflow obstruction in hypertrophie obstructive cardiomyopathy. Circulation 40: 3–11

    PubMed  CAS  Google Scholar 

  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: 984–995

    Google Scholar 

  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: 1039–1046

    Article  PubMed  CAS  Google Scholar 

  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: 516–521

    PubMed  CAS  Google Scholar 

  44. Popp R, Harrison D (1969) Ultrasound in the diagnosis and evaluation of therapy of idiopathic hypertrophic subaortic stenosis. Circulation 40: 905–914

    Google Scholar 

  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 6375

    Google Scholar 

  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: 337–345

    Article  PubMed  CAS  Google Scholar 

  47. Gilbert BW, Pollick C, Adelman AG, Wigle ED (1980) Hypertrophic cardiomyopathy: Subclassification by M-mode echocardiography. Am J Cardiol 45: 861–872

    Google Scholar 

  48. Wigle ED, Adelman AG, Auger P, Marquis Y (1969) Mitral regurgitation in muscular subaortic stenosis. Am J Cardiol 24: 698–706

    Article  PubMed  CAS  Google Scholar 

  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: 574–583

    Google Scholar 

  50. Eslami B, Aryanpur I, Tabaeezadeh M, Alipour M, Nazarian I, Shakibi JG (1979) Midventricular obstruction. Jap Heart J 20: 117–126

    Article  PubMed  CAS  Google Scholar 

  51. Falicov RE, Resnekov L (1977) Mid-ventricular obstruction in hypertrophic obstructive cardiomyopathy. New diagnostic and therapeutic challenge. Br Heart J 39: 701–705

    Google Scholar 

  52. Grose R, Maskin C, Spindola-Franco H, Yipintsoi T (1981) Production of left ventricular cavitary obliteration in normal man. Circulation 64: 448–455

    Article  PubMed  CAS  Google Scholar 

  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: 36–44

    Google Scholar 

  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: 833–848

    PubMed  CAS  Google Scholar 

  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: 821–826

    Article  PubMed  CAS  Google Scholar 

  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: 1100–1108

    Google Scholar 

  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 - 446

    Google Scholar 

  58. Wigle ED, Trimble AS, Adelman AG, Bigelow WG (1968) Surgery in muscular subaortic stenosis. Prog Cardiovasc Dis 11: 83–112

    Article  PubMed  CAS  Google Scholar 

  59. Bigelow WG, Trimble AS, Wigle ED, Adelman AG, Felderhof CH (1974) The treatment of muscular subaortic stenosis. J Thorac Cardiovasc Surg 68: 384–392

    PubMed  CAS  Google Scholar 

  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: 897–900

    PubMed  Google Scholar 

  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: 88–102

    PubMed  CAS  Google Scholar 

  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-128–132

    Google Scholar 

  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: 307–316

    PubMed  CAS  Google Scholar 

  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: 1205–1213

    PubMed  CAS  Google Scholar 

  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: 175–185

    Google Scholar 

  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: 850–860

    PubMed  CAS  Google Scholar 

  67. Binet JP, David P, Piot JD (1983) Surgical treatment of hypertrophic obstructive cardiomyopathies. Eur Heart J 4, suppl F: 191–195

    Google Scholar 

  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: 11601166

    Google Scholar 

  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: 187–190

    Google Scholar 

  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: 1127–1134

    Article  PubMed  CAS  Google Scholar 

  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: 215–223

    Google Scholar 

  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-82–87

    Google Scholar 

  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 - 447

    Google Scholar 

  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: 215–220

    Article  PubMed  CAS  Google Scholar 

  75. Losse B, Kuhn H, Loogen F, Schulte HD (1983) Exercise performance in hypertrophic cardiomyopathies. Eur Heart J 4, Suppl F 197–208

    Google Scholar 

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Author information

Authors and Affiliations

  1. Cardiology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA

    Barry J. Maron M.D. & S. E. Epstein

  2. National Institutes of Health National Heart, Lung, and Blood Institute, Building 10, Room 7B-15, Bethesda, Maryland, 20892, USA

    Barry J. Maron M.D.

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  1. Barry J. Maron M.D.
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  2. S. E. Epstein
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Editors and Affiliations

  1. Abteilung Kardiologie, Zentrum Innere Medizin, Theodor-Stern-Kai 7, 6000, Frankfurt 70, Germany

    M. Kaltenbach  & R. Hopf  & 

  2. Medizinische Poliklinik, Universität Erlangen, Östliche Stadtmauerstraße 29, 8520, Erlangen, Germany

    B. Kunkel

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

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Maron, B.J., Epstein, S.E. (1988). Dynamic obstruction to left ventricular outflow: The case for its existence in hypertrophic cardiomyopathy. In: Kaltenbach, M., Hopf, R., Kunkel, B. (eds) New Aspects of Hypertrophic Cardiomyopathy. Steinkopff. https://doi.org/10.1007/978-3-642-85369-2_12

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  • DOI: https://doi.org/10.1007/978-3-642-85369-2_12

  • Publisher Name: Steinkopff

  • Print ISBN: 978-3-642-85371-5

  • Online ISBN: 978-3-642-85369-2

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