case_images: PMC5425844_01
case_images: (a) At baseline, the transthoracic echocardiogram demonstrates moderately depressed LV function (LVEF-40%) with significant concentric and septal LV hypertrophy (LV mass 367 grams, IVSd-2.1 cm, PWT-1.5 cm, RWT-0.67). (b) There is further evidence of elevated filling pressures. There is left atrial enlargement (LA dimension-4.6 cm), mildly elevated estimated right ventricular systolic pressure (RVSP~36 mmHg), and restrictive filling on mitral inflow Doppler (E/A-2.3, deceleration time 190 milliseconds).
case_images: CRIC2017-7065759.001.jpg
case_images: PMC5425844_01_CRIC2017-7065759.001.jpg
case_images: fig1
case_images: The transthoracic echocardiogram was significant for moderately depressed left ventricular (LV) function, left atrial dilation, normal ventricular chamber dimensions, increased LV mass, and global hypokinesis (Figure 1).
case_images: Atrial fibrillation with rapid ventricular response (ventricular rate 127 bpm) with evidence of prior septal infarct and nonspecific ST-T wave abnormalities in the precordium. There are low QRS voltages noted across leads likely due to chronic obstructive pulmonary disease.
case_images: CRIC2017-7065759.002.jpg
case_images: PMC5425844_01_CRIC2017-7065759.002.jpg
case_images: fig2
case_images: The patient presented to the emergency department hypertensive (169/79 mmHg) and tachycardic with a ventricular rate of 127 beats per minute (Figure 2).
case_images: At the time of clinical deterioration, pulse Doppler of the LVOT and continuity equation calculated SV/CO (LVOT dimension-2.0 cm, VTI-8.1 cm) suggested low stroke volume (25 ml) and cardiac output (2.22 L/min).
case_images: CRIC2017-7065759.003.jpg
case_images: PMC5425844_01_CRIC2017-7065759.003.jpg
case_images: fig3
case_images: A pulse wave Doppler across the LVOT suggested diminished stroke volume after calculation of the LV velocity time integral (Figure 3).
case_images: Atrial fibrillation with fairly regular R-R intervals (ventricular rate 113 bpm) and slower rate while on beta-blocker. The QRS morphology and voltages remain unchanged from prior tracing.
case_images: CRIC2017-7065759.004.jpg
case_images: PMC5425844_01_CRIC2017-7065759.004.jpg
case_images: fig4
case_images: An EKG at the time demonstrated improvement of the ventricular rate without evidence of ST-T wave changes (Figure 4).