Figure 3.

A 47-year-old man with hypertrophic cardiomyopathy underwent exercise SE. At rest, peak gradient across the aortic valve was 12 mm Hg (panel (a)). Repeat assessment during a held Valsalva manoeuvre revealed that the peak gradient was now 63 mm Hg (panel (b)), which indicates that exercise-induced LVOT obstruction is highly likely. This was indeed confirmed that at peak stress, the maximum gradient had increased to 135 mm Hg (panel (c)). Note the late systolic peaking of the Doppler profile in panels (b) and (c), indicative of dynamic rather than fixed outflow tract obstruction. The patient was commenced on beta-blocker therapy following the test results.