Probably the first thing that occurs to most people
AMVL prolapse is less common than PMVL prolapse
Here you can see the highly eccentric, posteriorly directed jet of MR
This is the AP3Ch view showing the same abnormality
2. Systolic Anterior Motion (SAM)
SAM of the AMVL tends to (not always) produce posteriorly directed MR; important to remember that SAM is not the only reason a HCM patient may have MR
PLAX here is not mine, it's from an excellent lecture (on YouTube) by Dr @KyleWKlarich
Here you can see the posteriorly directed MR jet on colour Doppler imaging
Here is the still image
3. Ischaemic MR due to posterior leaflet restriction
Inferolateral / inferoposterolateral MI often produces a regional LV abnormality that affects the posteromedial papillary muscle & affects PMVL >> AMVL. The apical PM displacement tethers the PMVL, causing MR
PLAX view here
It may look like there's AMVL prolapse, but if you look closely you'll see the PMVL barely moves
Issue here is PMVL tethering due to inferolateral MI, causing apical displacement of PM pap muscle, thus tethering the leaflet
As a result, we see this highly eccentric, posteriorly directed MR jet
Here's a still frame of that MR jet
4. Atrial functional MR (AF-MR)
Huge atrial enlargement. There are multiple postulated mechanisms for MR in patients with AF - one is posterior leaflet tethering
Again, posteriorly directed MR jet seen here in AP4Ch view
MR still image...
A nice review on AF-MR in JACC Imaging details mechanisms of MR in such patients
Transthoracic echocardiography (TTE), when performed with care and diligence, can reveal a lot about the valve. TOE isn't necessary in all cases to determine leaflet pathology.
A worked example below:
In the PLAX view, you can assess the scallops of the leaflets
In a true PLAX view with aortic valve clearly visible, you mostly see the A2-P2 interface. Here, you can see a clear & large prolapse of the posterior leaflet
If you tilt upwards towards the PLAX RV outflow (pulmonary valve) view you see mostly the A1-P1 interface
Here, you can see the valve looks slightly different & no prolapse is seen
PE has garnered a reputation for huge profits as they typically buy into a company, aggressively ⬇️ costs whilst ⬆️ profit margins, leverage debt if needed, and then sell, often at a large profit
Does this matter when it comes to delivering healthcare services?
Sixty years ago this month - October 1963 - US cardiologist Dr Robert Bruce published a paper detailing his efforts to devise a multi-stage treadmill test
Little did he know this would go on to become the Bruce protocol the most widely used for exercise testing
A thread...
Prior to this, 'stress testing' to evaluate cardiac function was performed using the Masters 2-step technique, first described in 1935. This crude but simple test involved repeated steps up & down over 90 seconds
Bruce, amongst others, recognized the limitations of this test & set about developing an exercise treadmill test
His initial work focused upon a single stage protocol, but he soon realized this wasn't stressing fitter patients enough & the test was taking too long!
We know now that it is perfectly possible for symptomatic individuals to have abnormal stress tests, with inducible ischaemia, but not have significant epicardial CAD on angiography
So we should stop using epicardial CAD as the arbiter of whether the test is 'right' or 'wrong'
I helped recruit patients for #ISCHEMIA between 2012-13; we saw at least a dozen patients with barn door (core lab verified) abnormal stress tests but normal coronaries on angiography
Here is just one example! Rest on left, stress (exercise) on right...