• Images in cardiology

A 69 year old women was admitted to our hospital because of new onset palpitation. Physical examination revealed a heart rate 135 beats/min and a blood pressure of 200/120 mm Hg. On auscultation of the heart, a grade 2/6 systolic ejection murmur was heard at the third right intercostal space. Other physical findings were unremarkable. Electrocardiography revealed atrial fibrillation rhythm. Chest x ray findings were non-specific. Heart rate was controlled with a β blocker and blood pressure was lowered with an angiotensin converting enzyme inhibitor. The patient was transferred to echocardiography laboratory. Two dimensional echocardiographic examination revealed normal left ventricular size and function, and a highly mobile fibrous membrane attached the interventricular septum at the left ventricular outflow tract (LVOT) (below left, upper panel: AOV, aortic valve; LA, left atrium; LV, left ventricle). Aortic valves were fibrotic and a mild degree of aortic regurgitation was also detected. There was colour flow turbulence and 30 mm Hg pressure gradient in systole at the LVOT. Transoesophageal echocardiography (TOE) revealed left ventricular outflow obstruction caused by a discrete membrane which was highly mobile, moving to the left ventricular cavity in diastole and to the aortic valve in systole (below left, lower panel, and below right, upper panel: IVS, interventricular septum). Also, no thrombus was detected in the left atrium and left atrial appendage at TOE. Sinus rhythm was achieved by electrical cardioversion after unsuccessful medical cardioversion with propafenone and amiodarone. Cardiac magnetic resonance imaging confirmed the diagnosis of a discrete membrane at the level of the left ventricular outflow of the interventricular septum (below right, lower panel). Discrete suboartic membranes which cause subaortic stenosis are usually motionless. To the best of our knowledge, our patient was the first to be caused by flail suboartic discrete membrane.