Left ventricular diastolic gradient in hypertrophic cardiomyopathy☆

Systolic left ventricular (LV) gradients and diastolic dysfunction are widely studied in hypertrophic cardiomyopathy (HCM) [1,2], however diastolic gradients have never been described. A patient with HCM, mid-cavity obliteration and apical aneurysm, diagnosed by both 2D echocardiography (Fig. 1, panel A) and cardiac magnetic resonance (Fig. 1, panel B), showed color Doppler aliasing effect at mid-ventricle toward the LV apex of early (E) diastolic velocity (Fig. 1, panel C). At continuous Doppler, E velocity resulted to be bidirectional (Fig. 1, panel D); pulsed Doppler identified the LV level at which E was highest (Fig. 1, panels E and F). The pullback pressure trace from LV apex to base, found a peak systolic gradient of 130 mm Hg, and a mean diastolic gradient of 10 mm Hg (Fig. 2). Such a gradient was of 15 mm Hg starting at early diastole and ending at meso-diastole, suggesting that apex fills during systole and empties during early diastole when the basal chamber has lower diastolic pressure. Doppler LV mapping in diastole, may be useful to understand the pathophysiology of HCM, particularly in complex condition like that of mid cavity obliteration [3]. Furthermore, the impact of such a diastolic gradient on the response to exercise, reported to be a consequence of reduced cardiac output [4], may be of importance in the management of patients with HCM.