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Multiple milking in hypertrophic cardiomyopathy

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A 70 year old man with recent onset angina and deep T wave inversion on the lateral leads was referred for cardiac catheterisation. At angiography (lateral projection: A, diastole; B, systole) no coronary stenoses were found, but “multiple milking” of the mid left anterior descending coronary artery (up to 70% systolic narrowing, large arrow) and on the mid segment of two relatively large diagonal branches (both with 100% systolic narrowing, small arrows) was revealed. In addition, severe compression—with systolic disappearance—of three septal perforator branches was also visualised. Two dimensional (cross sectional) echocardiography disclosed asymmetric septal hypertrophy (anterior septum 22 mm, posterior wall 10 mm) with severe and diffuse involvement of the entire interventricular septum and anterolateral wall. No intraventricular gradient could be elicited at rest or after provocation. Dobutamine stress echocardiography was negative for ischaemia.

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