Concomitant Dynamic Left Ventricular Outflow Tract Obstruction and Severe Aortic Stenosis a Case Report and a Literature Review

We report the case of a 77-year-old woman presenting with a hypertrophic cardiomyopathy phenotype characterized by hemodynamically significant dynamic left ventricular outflow tract obstruction (LVOTO) due to mitral systolic anterior motion (SAM), in association with aortic stenosis (AS). The clinical presentation included an episode of syncope, followed by progressive exertional dyspnea. Initial transthoracic echocardiography revealed marked septal hypertrophy, a calcified aortic valve with elevated transvalvular gradients, and SAM-induced dynamic LVOTO. Sarcomeric hypertrophic cardiomyopathy (HCM) and its phenocopies were subsequently excluded from the study. Transesophageal echocardiography confirmed the coexistence of severe AS and SAM. Given the complexity of the patient's cardiac condition and the presence of a "porcelain aorta," both surgical and transcatheter aortic valve replacement were deemed high risk. We discuss the diagnostic and therapeutic challenges of this "double-threat" scenario - severe aortic stenosis combined with dynamic LVOTO - and review the relevant literature regarding its hemodynamic implications, imaging strategies, and management approaches, including the concept of the "suicide left ventricle".