Pseudoaortic stenosis produced by ventricular hypertrophy

Clinical History of Patients with Hypertrophic Cardiomyopathy-How to Improve the Initiation Process of the Diagnosis?

Background: Regardless of genetic origin and recommended screening methods, hypertrophic cardiomyopathy (HCM) is commonly diagnosed late in the advanced stages of the disease. The aim of this study was to analyse the case history of patients with HCM in order to obtain an initiation of the diagnostic process. Methods: This study was a retrospective, tertiary, single-centre cohort analysis of 85 consecutive pts with HCM (mean age at the time of HCM diagnosis: 51 ± 15 years; F/M: 42/43) who were hospitalized during the period from 1 January 2013 to 31 December 2022. Type of referral to the hospital, the reason for hospitalization as well as accompanying symptoms, comorbidities, and family history were analysed to obtain an initiation of the diagnostic process. The analysis was limited to hospitalizations in which the diagnosis of HCM was stated for the first time. Results: An analysis of the type of referral to the hospital revealed the following data: 18% of patients were admitted as urgent hospitalizations (UHs) and 82% as elective hospitalizations (EHs). Among the UHs, the majority of patients were transferred from another hospital (13%), and among the EHs, 65% of patients were referred from a specialised outpatient medical care (SMC) facility. The majority of patients in both the UH and EH groups were symptomatic: 84% in the EH group (the most common symptom was exertional dyspnea in 56% of pts) and 93% in the UH group (the most common symptom was syncope in 60% of pts). Among the analysed population, the most frequent comorbidities were systemic hypertension (51%), lipid metabolism disorders (38%) and obesity (23%). Conclusions: A diagnosis of HCM is often made at an advanced age in symptomatic patients, mainly during an EH. Nearly one-fifth of the Polish HCM population is diagnosed during a UH after a sudden event, which suggests the need for improvements in medical care in Poland.

Hypertrophic Cardiomyopathy-Past, Present and Future

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy with a prevalence of 1 in 500 in the general population. Since the first pathological case series at post mortem in 1957, we have come a long way in its understanding, diagnosis and management. Here, we will describe the history of our understanding of HCM including the initial disease findings, diagnostic methods and treatment options. We will review the current guidelines for the diagnosis and management of HCM, current gaps in the evidence base and discuss the new and promising developments in this field.

Hypertrophic cardiomyopathy. Clinical spectrum and treatment

HCM is a heterogeneous disease genotypically, phenotypically, pathophysiologically, clinically, and therapeutically. In decisions on the management of these patients, it is important to recognize this heterogeneity and to direct therapy at the predominant abnormalities.

Hypertrophic cardiomyopathy in identical twins

Hypertrophic cardiomyopathy was diagnosed in identical twin boys in early childhood. One underwent myomectomy at the age of 12 years because of progressive severe exertional dyspnoea accompanied by considerable obstruction of the left ventricular outflow tract shown on both echocardiography and cardiac catheterisation. Seven years later, at the age of 19, he remains incapacitated to a moderate degree. By contrast, the other twin has led a relatively normal life to date and no left ventricular outflow obstruction has been shown.

Hypercontractile cardiac states simulating hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) or idiopathic hypertrophic subaortic stenosis (IHSS) has been defined as an autosomal dominant myocardial disease characterized by specific physical findings, echocardiographic features, asymmetric septal hypertrophy and disordered myocardial architecture. Echocardiographic and scintiphotographic studies failed to reveal evidence of asymmetric septal hypertrophy in four patients with systolic anterior movement of the mitral valve and the typical ausculatory and peripheral pulse abnormalities characteristic of HCM. Postmortem examimination in one patient demonstrated mild concentric left ventricular hypertrophy and a normal arrangement of myocardial muscle fibers. These observations in four patients demonstrate that both systolic anterior movement of the mitral valve and the physical findings characteristic of HCM are not specific for the autosomal dominant myocardial disease characterized by asymmetric septal hypertrophy and abnormal septal histology.

Echocardiographic diagnosis of idiopathic hypertrophic cardiomyopathy without outflow obstruction

The echocardiographic findings of eight patients with hypertrophic cardiomyopathy without outflow obstruction (HMC) and of 15 normal (Norm) individuals are presented.

The characteristic features in HMC were: (1) interventricular septal width much greater than normal (HMC = 2.5 ± 0.3 cm, Norm = 1.0 ± 0.2 cm, P < 0.005); (2) normal or only slightly increased posterior left ventricular wall thickness; (3) the ratio of interventricular septal to posterior wall thickness ≧2.0; (4) ejection fraction greater than normal (HMC = 0.76 ± 0.08, Norm = 0.68 ± 0.06, P < 0.025); (5) reduced velocity of the early diastolic closing motion of the anterior mitral leaflet (HMC = 60 ± 23 mm/sec, Norm = 124 ± 29 mm/sec, P < 0.005); (6) absence of abnormal systolic movement of the anterior mitral valve, as seen in hypertrophic obstructive cardiomyopathy. The diagnosis of hypertrophic cardiomyopathy can be made with echocardiography, even when outflow tract obstruction of the left ventricle is absent.

Angiographic anatomy of the left ventricle and mitral valve in idiopathic hypertrophic subaortic stenosis

The angiographic features of the left ventricle were examined in patients with idiopathic hypertrophic subaortic stenosis who had clinical and hemodynamic evidence of obstruction. Of 36 combined hemodynamic and angiographic studies considered to be technically satisfactory, 33 showed a characteristic combination of abnormalities. In the frontal projection in systole, a linear radiolucent area extended across the left ventricular outflow tract 2 to 2.5 cm below the aortic annulus, at a level corresponding to the site of intraventricular pressure change. In the left oblique and lateral projections, the mitral leaflets did not swing posteriorly in a normal fashion, but projected into the outflow tract during mid and late systole. The radiolucent line, seen in the frontal views, was considered to represent contact of the leading edge of the leaflet with the hypertrophied muscular interventricular septum. The jet of mitral regurgitation, when present, was seen immediately below the anterior mitral leaflet.

Severe hypertrophy was also seen to involve the inferior portion of the muscular septum, causing displacement of the papillary muscles superiorly and to the left. This maldirection of the papillary muscles was postulated to cause abnormal traction on the chordae tendineae and to prevent normal movement of the mitral leaflets away from the septum during systole. The leaflets, held in the outflow tract, form the posterior component of the obstruction, the anterolateral component of which results from severe, asymmetric septal hypertrophy. It was proposed that this mechanism plays an important part in producing the intraventricular pressure gradient in many patients with idiopathic hypertrophic subaortic stenosis.

Familial myocardial disease with and without obstruction to left ventricular outflow. Clinical, hemodynamic, and angiographic findings

Right and left heart catheterization, including selective cineangiocardiography, was performed in 20 of the 33 patients examined in a large Negro family. Fifteen had features compatible with the diagnosis of idiopathic hypertrophic subaortic stenosis. Sudden death has not occurred in this family. Many of the patients were young and were totally unaware of the heart disease, although 11 had symptoms of dyspnea on exertion. A large number of individuals in this family were found to be affected by a familial form of heart disease with similar clinical manifestations, but with a wide spectrum of hemodynamic and cineangiocardiographic abnormalities ranging from no obstruction to ventricular outflow and only mild indentation of the ventricular cavity to obstruction and marked narrowing of both ventricular outflow tracts. The patients with obstruction of the left ventricular outflow tract were older than those without obstruction. Therefore, this study provides further evidence that in families with myocardial disease, the presence or absence of outflow tract obstruction is merely a different manifestation of the same basic cardiac disease. This study has also demonstrated distinct left ventricular abnormalities quite early in life suggesting that the disease may be of congenital origin and that obstruction may be a function of the duration of the disease.

The electrocardiogram in muscular subaortic stenosis. Effect of a left septal incision and right bundle-branch block

The electrocardiograms of four patients with muscular subaortic stenosis, in whom there was angiographic evidence of ventricular septal hypertrophy (confirmed at surgery in three), revealed pathological Q waves in the limb leads (except aV R ) and the left precordial leads, as well as tall R waves in the right precordial leads. Three patients underwent surgical correction of the stenosis. The left anterior septal ventriculomyotomy abolished the Q waves and diminished the right precordial R waves while at the same time producing left axis deviation believed to be due to severing of the anterior division(s) of the left bundle branch. In the fourth patient the left precordial and limb lead Q waves and right precordial R waves increased following spontaneous development of complete right bundle-branch block. These observations support the belief that the Q-wave and R-wave abnormalities in the electrocardiogram in patients with muscular subaortic stenosis are the result of septal depolarization commencing at the left septal surface and may be related to the overall hypertrophy of the septum, the bizarre myocardial fiber hypertrophy or premature activation of the base of the septum, or all three.

Transatrial and transaortic approaches to subvalvular left ventricular outflow tract obstruction. Correction of associated anomalies in children

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Heart failure from unexplained cardiomyopathy

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Hypertrophic subaortic stenosis with myocardial fibre degeneration

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