Abnormal course, abnormal flow, and systolic compression of the septal perforator associated with impaired myocardial perfusion in hypertrophic cardiomyopathy

The septal perforators in hypertrophic cardiomyopathy (HCM) show systolic compression. The compression is thought to be related to the malpositioned septal perforators, but its relation to the development of myocardial ischemia remains controversial.We examined echocardiographically the blood flow and course of the major septal perforator in 142 consecutive patients with HCM; of these, 94 underwent coronary angiography to assess systolic compression of the septal perforators and 110 had thallium-201 scintigraphy. We then analyzed the relation of the findings in comparison with the results in 15 patients with valvular aortic stenosis (AS).The major septal perforator was visualized in 82 patients with HCM and in 8 patients with AS. The visualization did not depend on the pressure gradient between the left ventricle and aorta in the HCM patients, but did in the AS patients. In AS the perforator always showed a normal course near to, and convexly toward, the right ventricle. In 71 of the 82 HCM patients, the perforator was distant from the right-sided endocardium of the ventricular septum and often convex toward the left. The greater the leftward deviation, the higher was the grade of compression. In 48 of the 82 patients with HCM and in all of the 8 patients with AS who showed the flow signal, the septal perforator showed systolic retrograde flow; in the patients with HCM there was a significant correlation (r = 0.54, P.05) between the peak velocity and the degree of leftward deviation. Furthermore, higher degrees of the leftward deviation and higher degrees of the systolic compression of the major perforator were each associated with a higher incidence of exercise-induced defect of thallium-201.The echocardiographic, angiographic, and scintigraphic findings in HCM may be closely related to one another. We speculate that the series of abnormalities is initiated by a high intramural pressure and impedance on the septal perforators due to their deviation toward the left.