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Chest pressure and dyspnoea in a 47-year-old man
  1. Sushan Yang,
  2. John K Feller,
  3. Eric Krieger
  1. Cardiology, University of Washington, Seattle, Washington, USA
  1. Correspondence to Dr Sushan Yang, Cardiology, University of Washington, Seattle, WA 98195, USA; susany90{at}

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Clinical introduction

A 47-year-old man presents with exertional dyspnoea and chest pressure. He also reports occasional palpitations and postural syncope. Cardiovascular exam is notable for a blood pressure of 116/76 mm Hg, regular rate and rhythm, normal S1 and S2, with no jugular venous distension and no oedema. A murmur is noted. ECG shows left ventricular hypertrophy and repolarisation abnormalities. A transthoracic echocardiogram was obtained, and an M-mode recording of the mitral valve is shown in figure 1.

Figure 1

M-mode examination (A) and colour M-mode examination (B) of the mitral valve.

Which of the following is the most likely diagnosis?

  1. Mitral valve prolapse.

  2. Hypertrophic cardiomyopathy.

  3. Mitral stenosis.

  4. Aortic regurgitation.

  5. Dilated cardiomyopathy.

Answer: B

M-mode echocardiography shows evidence of hypertrophic cardiomyopathy. There is systolic anterior motion of the mitral valve with contact between the anterior leaflet and the interventricular septum. Asymmetric septal thickening is present. Colour M-mode images show turbulence through the left ventricular outflow tract and posteriorly directed mitral regurgitation.

Mitral valve prolapse may demonstrate posterior displacement of the mitral leaflets ≥2 mm in late systolic or ≥3 mm in pansystolic prolapse.1 In the images shown here, however, the mitral leaflets are displaced anteriorly during systole.

Mitral stenosis shows restricted leaflet opening on M-mode. Additionally, the A point may be absent and diastolic anterior motion of the posterior leaflet may occur due to doming, which are not seen here.

Severe aortic regurgitation may obstruct the mitral valve anterior leaflet, which manifests on M-mode as high-frequency, diastolic fluttering with reduced leaflet opening and early leaflet closure (creating the Austin Flint murmur). In cases of aortic regurgitation, colour M-mode may demonstrate diastolic flow above the anterior leaflet.

Elevated left ventricular end-diastolic pressure (LVEDP) may lead to a ‘B-bump’ on M-mode, or a plateau between the A point and mitral valve closure. This occurs when LVEDP exceeds left atrial pressure after atrial contraction, often when LVEDP is ≥20 mm Hg, causing tapered leaflet closure.2



  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

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

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