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Visualisation of systolic myocardial perfusion defect induced by septal squeezing

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A 58 year old woman presented with exertional dyspnoea and chest pain. Cross sectional and Doppler echocardiography revealed asymmetric septal hypertrophy, systolic anterior movement of the anterior mitral leaflet, and left ventricular outflow obstruction with a pressure gradient of 108 mm Hg. The patient underwent right and left heart catheterisation, including right ventricular endocardial biopsies, and was diagnosed with hypertrophic obstructive cardiomyopathy. Coronary arteriography revealed prominent systolic myocardial squeezing of the septal branches of the left anterior descending artery with no significant arterosclerotic stenosis (top, arrowheads). We performed myocardial contrast echocardiography with ECG triggered harmonic Doppler technique using intravenous Levovist (a saccharide based transpulmonary echo contrast agent; Schering AG). The image triggered at end diastole showed homogeneous myocardial opacification (bottom, left). In contrast, the end systolic image showed a myocardial perfusion defect at the proximal septum which was consistent with coronary arterial squeezing (bottom, right). This unusual case illustrates the use of myocardial contrast echocardiography to identify the difference in coronary perfusion between diastole and systole.