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Updated: Sep 14, 2025

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Reverse Bernheim Phenomenon - A True Enigma.

Evan Wasserman1, Luis Wulff1, Debabrata Bandyopadhyay1

  • 1University of South Florida, Geisinger Health, United States.

Respiratory Medicine Case Reports
|July 21, 2025
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Summary
This summary is machine-generated.

This case study highlights the reverse Bernheim phenomenon in a patient with heart failure and pulmonary arterial hypertension. Escalating therapy resolved exercise-induced syncope by improving right ventricular function.

Keywords:
Bernheim syndromeDiastolic dysfunctionInterventricular septumLVOT obstructionPAH specific treatmentPulmonary arterial hypertensionRV dysfunctionReverse bernheim syndromeVentricular interdependence

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Area of Science:

  • Cardiology
  • Pulmonology
  • Medical Imaging

Background:

  • A 70-year-old male with heart failure with preserved ejection fraction (HFpEF) and pulmonary arterial hypertension (PAH) presented with worsening dyspnea and syncope.
  • Previous treatment included ambrisentan, sildenafil, and selexipag, with recent right heart catheterization showing improved mean pulmonary arterial pressure but worsened pulmonary capillary wedge pressure.

Observation:

  • Resting echocardiography revealed normal left ventricular systolic function with right ventricle (RV) dilatation and dysfunction.
  • During stress echocardiography, the patient experienced syncope, hypotension, and oxygen desaturation, with images showing significant exercise-induced RV dilatation and septal bulging compressing the left ventricular outflow tract (LVOT) - the reverse Bernheim phenomenon.

Findings:

  • The RV size and function normalized at rest.
  • Escalation of PAH therapy with intravenous treprostinil improved exercise capacity and resolved syncopal episodes.
  • Repeat stress echocardiography demonstrated resolution of RV dilatation and septal bulging without LVOT compression.

Implications:

  • The reverse Bernheim phenomenon can cause exercise-induced syncope in patients with PAH and HFpEF.
  • Aggressive management of PAH, including advanced therapies like intravenous prostacyclin, can effectively treat this condition.
  • Stress echocardiography is crucial for diagnosing dynamic LVOT obstruction secondary to RV dysfunction.