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Real questions from EchoScholar

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๐ŸŽฌ Cine Loop Question

Review these paired parasternal short axis cines at the level of the aortic valve. The 2D view shows disruption at the base of the aorta, and the color Doppler view reveals an abnormal high-velocity jet directed into an adjacent cardiac chamber. What is the diagnosis?

A. Ruptured sinus of Valsalva (SOV) aneurysm โœ“
B. Perimembranous ventricular septal defect (VSD)
C. Aortic regurgitation with eccentric jet
D. Coronary artery fistula
Show Explanation

A ruptured sinus of Valsalva (SOV) aneurysm produces a continuous shunt from the high-pressure aorta into an adjacent low-pressure chamber. The right coronary sinus most commonly ruptures into the right ventricle; the non-coronary sinus most commonly ruptures into the right atrium. Color Doppler demonstrates a characteristic continuous, high-velocity jet at the aortic root level โ€” not at the interventricular septum as in a VSD. The clinical presentation is often acute onset of chest pain and a continuous 'machinery' murmur. The finding is distinct from aortic regurgitation, which produces a diastolic jet directed into the LVOT.

ASE Guidelines for Performing a Comprehensive Adult TTE: Mitchell C et al., J Am Soc Echocardiogr. 2019;32(1):1โ€“64.

๐Ÿ–ผ๏ธ Image Question
CW Doppler tracing showing late-peaking dagger-shaped signal in LVOT

This CW Doppler tracing from the apical 5-chamber view demonstrates a late-peaking, concave, 'dagger-shaped' systolic signal in the LVOT. How does this waveform morphology differ from valvular aortic stenosis, and what diagnosis does it indicate?

A. Hypertrophic obstructive cardiomyopathy (HOCM); the late-peaking dagger shape reflects dynamic obstruction that worsens as the LV empties in systole โœ“
B. Valvular aortic stenosis; a dagger-shaped waveform is the classic morphology of severe fixed AS
C. Hypertrophic obstructive cardiomyopathy; the signal is early-peaking because obstruction is greatest at the start of systole
D. Subaortic membrane; fixed subvalvular obstruction produces a late-peaking waveform identical to HOCM
Show Explanation

The CW Doppler waveform morphology is a key differentiator between fixed and dynamic LVOT obstruction. In HOCM, the obstruction is dynamic โ€” it increases progressively during systole as the ventricle empties and the LVOT narrows due to SAM. This produces a characteristic late-peaking, concave, dagger-shaped waveform. In valvular aortic stenosis, the obstruction is fixed, producing a rounded, symmetric waveform that peaks in early-to-mid systole. The dagger shape is pathognomonic for dynamic obstruction. Additionally, HOCM gradients increase with provocative maneuvers that decrease preload (Valsalva, standing) and decrease with maneuvers that increase preload (squatting, passive leg raise).

AHA/ACC Hypertrophic Cardiomyopathy Guidelines: Ommen SR et al., J Am Coll Cardiol. 2020;76(25):e159โ€“e240.

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