Triphasic mitral inflow pattern and regional triphasic mitral annulus velocity in hypertrophic cardiomyopathy

In Doppler echocardiography, a triphasic mitral inflow filling pattern with a mid-diastolic flow velocity (L) is usually related to elevated filling pressures and delayed myocardial relaxation. Furthermore, additional triphasic mitral annulus velocity with a mid-diastolic component (L') at tissue Doppler imaging (TDI) demonstrates an even more advanced diastolic dysfunction. In this puzzling case, a triphasic and restrictive mitral inflow pattern was noted in 55-year-old patient with Hypertrophic Cardiomyopathy and a history of septal myectomy. Interestingly, E' was reduced (< 0.1 m/s) and a mid-diastolic component (L') was recorded by TDI in the septal corner of the mitral annulus. However, E' was near normal (> or = 0.1 m/s) in the lateral mitral annulus. Upon contrast-enhanced cardiac MRI, severe septal scarring could be visualized as delayed hyperenhancement corresponding to the region of restrictive and triphasic diastolic function. Therefore, advanced regional diastolic dysfunction in the septum could be demonstrated by localized triphasic mitral annulus velocity as a correlate of pronounced scarring.