• Images in cardiology

A 15 year old girl presented with fatigue and dyspnoea on exertion. She had an ejection murmur at the left sternal border. A chest radiograph showed cardiomegaly and the ECG showed left ventricular hypertrophy with a strain pattern. The echocardiogram confirmed left ventricular hypertrophy, with outflow obstruction caused by subaortic stenosis at two separate levels, one immediately proximal to the aortic valve appearing as a fibrous ridge (upward arrow) and the other as a discrete membrane. Cardiac catheterisation confirmed two discrete intracavitary pressure gradients. Subaortic stenosis is usually caused by a discrete membrane or fibromuscular ridge and may very rarely be due to a fibrous tunnel involving the whole left ventricular outflow tract. Obstruction caused by two separate but very discrete membranes as occurred in our patient also appears to be very rare. At operation both obstructions were resected and the patient made a good recovery. She will, however, require long term follow up as recurrence of subaortic stenosis after surgical treatment is known to occur in a proportion of cases.