case_images: PMC5926514_01
case_images: Echocardiogram showing 75 mmHg gradient in the left ventricular outflow tract with Valsalva.
case_images: CRIC2018-8714819.001.jpg
case_images: PMC5926514_01_CRIC2018-8714819.001.jpg
case_images: fig1
case_images: After Valsalva maneuver, the LVOT gradient increased strikingly to 75 mmHg (Figure 1) with a further increase to 81 mmHg after administration of amyl nitrite.
case_images: Cardiac MRI showing multiple heads of the posteromedial papillary muscle in the three chamber view (a), four chamber view (b), and short axis view (c), with a suggestion of an abnormal chordal attachment to the anterior mitral valve leaflet (red arrow). Delayed gadolinium imaging (d) showing no increased signal.
case_images: CRIC2018-8714819.002.jpg
case_images: PMC5926514_01_CRIC2018-8714819.002.jpg
case_images: fig2
case_images: There was a suggestion that the more anteriorly displaced head of the posteromedial papillary muscle had aberrant chordal attachments to the anterior mitral valve leaflet that contributed to the SAM (Figure 2).
case_images: Long axis of the LV from a deep transgastric view using transesophageal echocardiography. LV = left ventricle, PM = posterior papillary muscle, and Ao = aorta. During midsystole, there is anterior motion of the apically displaced posterior papillary muscle (red arrow).
case_images: CRIC2018-8714819.003.jpg
case_images: PMC5926514_01_CRIC2018-8714819.003.jpg
case_images: fig3
case_images: A subsequent transesophageal echocardiogram (TEE) demonstrated the mobile anteriorly displaced posterior papillary muscle with SAM (Figure 3).