Doppler color flow mapping studies of jet formation and spatial orientation in obstructive hypertrophic cardiomyopathy

To help clarify the mechanism of outflow tract obstruction and systolic anterior motion of the anterior leaflet of the mitral valve and their relation to the geometry of the left ventricle, we studies left ventricular outflow tract flow in 20 patients with hypertrophic cardiomyopathy (HCM) using two-dimensional Doppler flow mapping. We compared our results with outflow tract flow in 10 patients with isolated valvular aortic stenosis, (AS) and with those in 10 healthy volunteers. In HCM, a 94- to 145-degree angle (mean 111.4 ± 11.9 degrees) developed between the direction of left ventricular outflow tract flow acceleration and aortic valve outflow, resulting in posterolaterally directed left ventricular outflow jets. The angle of the outflow jet and the peak velocity of the jet measured with continuous wave Doppler (as an indicator of the severity of obstruction) correlated well (r = -0.81, SEE = 7.8 degrees). Jet narrowing during ejection measured just proximal to the point of systolic anterior motion was 42 ± 11% in HCM and was outflow occurred proximal to systolic anterior motion of the mitral valve, and color M-mode demonstrated temporal and spatial flow acceleration proximal to systolic anterior motion, providing evidence for obstruction at that site. In AS, left ventricular outflow tract jets were more parallel to the axis of aortic outflow (129 to 153 degree, 138.4 ± 8.1 degrees). Jet narrowing was only 8 ± 5% compared to HCM (both p < 0.05), and flow acceleration occurred proximal to the stenotic valve. In normal subjects, turbulent jets were not observed and the angle between left ventricular outflow tract flow and aortic flow was 149.6 ± 2.5 degrees. Our results are consistent with a venturi effect proximal to the mitral valve contributing to the development of systolic anterior motion and outflow tract obstruction, and highlight the importance of ventricular geometry as a determinant of obstruction in HCM.