IMAGES IN MEDICINE Corresponding author:

A 73- year- old woman with a previous diagnosis of hypertrophic obstructive car-diomyopathy (HOCM) and severe mitral regurgitation was scheduled for transaortic septal myectomy (Morrow procedure) and mitral reconstruction/replacement. After anesthesia induction, a transesoph-ageal echocardiography (TEE) was per-formed in order to assess the extent and site of myectomy required and to clarify the mechanism of the mitral regurgitation (MR). TEE confirmed subaortic left ventricular outflow tract (LVOT) obstruction (peak velocity 6,5 m/sec, mean gradient of 80 mmHg) (Figure 1). Asymmetric left ventricular hypertrophy involving the interventricular septum (19 mm at end diastole) and systolic anterior motion (SAM) of the mitral valve with septal contact (at a distance of 2 cm from the aortic valve) were also evidenced. TEE pointed SAM as the likely cause of MR (Figure 2). The MR jet was posteriorly directed and apart from thickened leaflets and mild mi-tral annulus calcification no other anomaly Severe mitral regurgitation treated by ventricular septal myectom