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?

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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