In this study we present the dynamics of a patient undergoing ASA for medically refractory symptoms. We illustrate how the Brockenbrough-Braunwald-Morrow sign can be used to determine accurately the degree of LVOT obstruction during and

after ASA in a patient without a resting gradient. Case A 62-year-old female with a past medical history of hypertension presented to the clinic complaining of dyspnea on exertion and chest discomfort that had been progressing over the Inhibitors,research,lifescience,medical last 6 months. The shortness of breath was such that she had to stop her exercise routine. She denied orthopnea or paroxysmal nocturnal dyspnea as well as any syncopal episodes. On physical examination, her blood pressure was 138/77 mm Hg and pulse was 69 per minute. On neck exam her carotids showed a brisk upstroke without jugular venous distention. On cardiac auscultation, a systolic II/VI murmur at the left sternal border with radiation to the axilla was Inhibitors,research,lifescience,medical appreciated. The murmur increased during the strain phase of valsalva. There was no pitting edema in the lower extremities. Electrocardiogram Inhibitors,research,lifescience,medical showed sinus rhythm, possible left atrial enlargement, and small R waves in leads V2 and V3. Echocardiogram revealed

moderate asymmetric left ventricular hypertrophy (LVH) and an interventricular septum diastolic thickness of 1.7 cm. The wall motion was hyperdynamic, with cavity obliteration and an estimated LV ejection fraction (LVEF) of > 70%. There was systolic anterior motion of the mitral valve, and moderate mitral regurgitation with an eccentric jet directed posterolaterally. Inhibitors,research,lifescience,medical Agitated contrast resulted in opacification of the basal and mid-septal segments. Left ventricular outflow tract MAPK inhibitor gradient at rest was 100 mm Hg and increased to 131 mm Hg with valsalva. Her left atrium was severely enlarged with a left atrial volume of 96 mL. The Holter monitor was notable for a run of nonsustained ventricular tachycardia. Cardiac magnetic resonance imaging showed similar findings to the echo: a hyperdynamic ventricle (LVEF 75%) with moderate asymmetric LVH (septal 1.5 cm) causing LVOT flow turbulence and chordal systolic anterior motion. It also revealed a patchy midmural septal Inhibitors,research,lifescience,medical scar that was in a non-coronary artery

disease pattern. When initially seen, the patient was taking candesartan 32 mg daily almost and hydrochlorothiazide 12.5 mg daily. Her medications were changed to metoprolol 25 mg extended release daily, as vasodilators and diuretics worsen the LVOT obstruction in patients with hypertrophic obstructive cardiomyopathy (HOCM). Despite these mediation changes, after 1 month on the beta blocker she had no improvement with her dyspnea on exertion or chest pain. The patient reported feeling fatigued since she started the metoprolol and felt she would not tolerate an increase in the dose. We discussed septal myectomy and ASA, and she agreed to proceed with ASA. Bilateral femoral artery (7-Fr right and 4-Fr left) and femoral vein (6-Fr right) access was obtained.