A 74-year-old woman was referred to our hospital for evaluation of increasing dyspnea and fatigue. Her electrocardiogram showed marked left ventricular (LV) hypertrophy and T-wave inversion over leads V₃ to V₆(A). Transthoracic echocardiography demonstrated significant aortic stenosis (AS) and gross asymmetrical LV hypertrophy (B, Online Videos 1, 2, and 3), which caused combined subaortic and mid-ventricular obstruction. Doppler echocardiography demonstrated triphasic severe pressure gradients through the LV outflow tract (LVOT), mid-peaking symmetric velocity, and 2 asymmetric late-peaking “dagger-shaped” velocities. The subaortic gradient reached a peak in mid-systole, and the mid-ventricular gradient reached a peak in late systole and persisted to early diastole (C, Online Videos 4 and 5). Cardiac magnetic resonance imaging showed marked asymmetrical LV hypertrophy (D). A left ventriculogram also revealed dynamic mid-cavity and LVOT obliteration (E) (Online Video 6). Coronary angiography showed normal vessels.

The patient was diagnosed with multiple levels of LVOT obstruction with significant AS. Septal myectomy and aortic valve replacement were successfully performed. This case highlighted the significance of meticulous examination by Doppler echocardiography for evaluation of dynamic LVOT obstruction.