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Image challenge
56-year-old lady with transaortic gradient
  1. Roberto Spina1,
  2. Arjun Iyer2,
  3. Paul Jansz2
  1. 1 Department of Cardiology, St Vincent’s Hospital, Sydney, New South Wales, Australia
  2. 2 Department of Cardio-Thoracic Surgery, St Vincent’s Hospital, Sydney, New South Wales, Australia
  1. Correspondence to Dr Roberto Spina, Department of Cardiology, St Vincent’s Hospital, Sydney, NSW 2010, Australia; roberto.spina{at}


Clinical introduction A 56-year-old lady with a background of hypertension was admitted to our institution with acute pulmonary oedema. She reported gradual and increasingly severe dyspnoea on exertion over the preceding 12 months and, prior to presentation, her exercise tolerance was restricted to one flight of stairs. On transthoracic echocardiography during the index admission, left ventricular size and systolic function were normal, and peak and mean transaortic gradients were 67 mm Hg and 33 mm Hg, respectively, with a peak velocity of 3.9 m/s. No aortic incompetence or other significant valvular abnormality was noted. A transoesophageal echocardiogram was performed. Figure 1 depicts the mid-oesophageal parasternal long-axis view. What is the explanation behind the significant transaortic gradient?

Figure 1

Transoesophageal echocardiogram, mid-oesophageal long-axis view at 135 degrees.

Question What is the explanation behind the significant transaortic gradient?

  1. Ventricular septal defect 

  2. Supravalvular aortic stenosis

  3. Aortic valvular stenosis

  4. Subaortic membrane

  5. Hypertrophic obstructive cardiomyopathy

  • aortic stenosis
  • hypertrophic cardiomyopathy
  • valvular heart disease
  • valve disease surgery

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  • Contributors RS: provided direct care of the patient, established the diagnosis of subaortic membrane and referred the patient for surgical intervention. Prepared the manuscript and the imaging. AI: assisted with the collection of the surgical and histopathological images. PJ: provided overall guidance to the project. Performed the open heart procedure on the patient.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.