Anomalous Papillary Muscle Insertion Causing Dynamic Left Ventricular Outflow Tract Obstruction without Hypertrophic Obstructive Cardiomyopathy

Figure 1

Transthoracic and transesophageal echocardiographic findings. (a) Pulse-wave Doppler at the LVOT showing a peak velocity of 3.94 m/s and gradient 62 mmHg. The waveform contour is dagger-shaped. (b) Strain-phase Valsalva results in an increase in peak velocity to 4.56 m/s with gradient 83 mmHg. (c) Apical view at end-diastole showing no significant LVOT narrowing. The septal wall shows moderately increased thickness measured at 1.4 cm. (d) Apical view during systolic phase showing mitral-septal contact (white arrow) consistent with SAM. (e) Color Doppler showing severe, posteriorly directed mitral regurgitation (dashed arrow) into a moderately enlarged left atrial cavity and significant turbulence across the LVOT (solid arrow). (f) Transgastric short-axis view at the level of the mitral valve during systolic phase, showing a large echodensity attached to lateral scallop of the anterior mitral leaflet (arrowheads).

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