J Korean Soc Echocardiogr.  1995 Jul;3(1):44-48. 10.4250/jkse.1995.3.1.44.

Clinical and Echocardiographic Features of Mid-ventricualr Obstruction of the Left Ventricle

• Kim SH
• Park JC
• Seo JP
• Cho IJ
• Rhe MH
• Gill GC
• Park JH
• Jeong MH
• Cho JG
• Kang JC

• KMID: 2410432
• DOI: http://doi.org/10.4250/jkse.1995.3.1.44

Abstract

BACKGROUND
Mid-ventricular obstruction(MVO) of the left ventricle has been reported to be associated with mid-ventricular hypertrophy, papillary muscle hypertrophy, severe apical hypertrophy, elderly hypertension, and dobutamine stress echocardiography(DSE). The aim of this study is to determine the clinical and echocardiographic features of MVO. METHOD: MVO was defined as systolic hourglass narrowing of the left mid-ventricle in the apical long axis view with turbulent flow exceeding 1m/s. Fifteen patients were suvjected to this retrospective analysis. Baseline patients characteristics were mean age 56(range, 26-74)years, male gender 10(66%). Associated diseases were hypertrophic cardiomyopathy 9, aortic stenosis 1, hypertension without left ventricular hypertrophy(LVH) 1, old myocardial infarction with apical aneurysm 2, stable angina 1, and idiopathic 1. DSE was performed in 7 of 15 subjected patients to evaluate the chest pain.
RESULTS
All patients had mild symptoms; chest tightness, palpitation, and weakness, without syncope nor hypotension. MVO was observed in 10 at rest, and 5 after provocation ; DSE 3, VPB 1, atropine 1. Observed peak velocity in the mid-ventricle ranged from 1.2 to 5.5m/s(mean ; 2.8±1.6m/s). Left ventricular outflow tract obstruction defined as the peak flow velocity exceeded 1.5m/s, was also present in 8. in 7 underwent to DSE, systolic blood pressure was changed from 144±15mmHg at rest to 175±28mmHg at peak, heart rate from 73±12/min to 108±23/min, left ventricular end diastolic dimension from 42±5mm to 37±4mm, ejection fraction from 66±10% to 80±6%, and peak flow velocity at the mid-ventricle from 1.0±0.6m/s to 3.3±1.7m/s.
CONCLUSION
MVO can be observed in patients without LVH and may account for clinical symptoms of chest discomfort. The mechanism of MVO, at least in part, and be explained with increased ventricular contractility, increased heart rate, and small left ventricular cavity size.

Keyword

Mid-ventricular obstruction; Dobutamine stress echocardiography

MeSH Terms

Aged
Aneurysm
Angina, Stable
Aortic Valve Stenosis
Atropine
Blood Pressure
Cardiomyopathy, Hypertrophic
Chest Pain
Dobutamine
Echocardiography*
Echocardiography, Stress
Heart Rate
Heart Ventricles*
Humans
Hypertension
Hypertrophy
Hypotension
Male
Methods
Myocardial Infarction
Papillary Muscles
Retrospective Studies
Syncope
Thorax
Atropine
Dobutamine

Reference

References

1). Falicov RE, Resnekov L, Bharati S, Lev M. Mid-ventricular obstruction: A variant of obstructive cardiomyopathy. Am J Cardiol. 37:432–437. 1976.

2). Wigle ED, Sasson Z, Henderson MA, et al. Hypertrophic cardiomyopathy: The importance of the site and the extent of hypertrophy. A Review. Prof Cardovasc Dis. 28:1–83. 1985.

3). Zoghbi WA, Haichin RN, Quiones MA. Mid-cavity obstruction in apicial hypertrophy: Doppler evidence of diastolic intraventricular gradient with higher apical pressure. Am Heart J. 116:1469–1474. 1988.

4). Bruyne B, Marchandise B, Kremer R. Apical hypertrophic cardiomyopathy of the Japanese type in Western countries. Am J Med. 82:1087–1088. 1987.

5). Louie EK, Maron BJ. Apical hypertrophic cardiomyopathy clinical and two-demensional echocardiographic assessment. Ann Intern Med. 106:663–670. 1987.

6). Maron BJ, Bonow RO, Seshagiri TNR, Roberts WC, Epstein SE. Hypertrophic cardiomyopathy with ventricular sepal hypertrophy localized at the apical region of the left ventricle (apical hypertrophic cardiomyopathy). Am J cardiol. 49:1838–1848. 1982.

7). Sutsch G, Jenni R, Krayenbuhl HP. Left ventricular flow from apex to base during systole and isovolumic relaxation in a patient with hypertrophic cardiomyopathy and midventricular obstruction. European Heart Journal. 12:1132–1139. 1991.

8). Barbier P, Bartorelli AL. Doppler evidence of abnormal intracavitary systolic and diastolic flow in hypertrophic cardiomyopathy with midventricular obstruction. Am Heart J. 126(2):483–487. 1993.

9). Gordon EP, Henderson MA, Rakowski H, Wingle ED. Midventricular obstruction with apical infarction and aneurysm formation <Abstract>. Circulation. 70(supp2):145. 1994.

10). Harrison MR, Grigsby CG, Souther SK, Smith Demaria. Midventricular obstruction associated with chronic systemic hypertension and severe left ventricular hypertrophy. Am J Cardiol. 68(8):761–765. 1991.

11). Blazer D, Kotler MN, Parry WR, Qertheimer J, Nakhavan FK. Noninvasive evaluation of mid-left ventricular obstrucition by two-dimensional and Doppler echocardiography and color flow Doppler echocardiography. Am Heart J. 114:1162. 1987.

12). Pellikka PA, Oh JK, Bailey KR, Nichols BA, Monahan KH, and Tajik AJ. Dynamic Intraventricular Obstruction During Dobutamine Stress Echocardiography. Circulation. 86:1429–1432. 1992.

13). Hoffmann R, Lethen H, Kleinhans E, Weiss M, Flachskampf FA, Hanrath P. Comparative Evaluation of Bicycle and Dobutamine Stress Echocardiography with Perfusion Scintigraphy and bicycle Electrocardiogram for Identification of Coronary Artery disease. Am J Cardiol. 72:555–559. 1993.