Detection of Midapical Obstruction in Hypertrophic Cardiomyopathy via Midsystolic Doppler Signal Absence

Overview

This retrospective study evaluated the prevalence and clinical correlates of a midsystolic Doppler signal void in patients with hypertrophic cardiomyopathy (HCM) and assessed whether it identifies a distinct midapical obstructive phenotype.

Background

Midapical obstruction represents a distinct anatomic and hemodynamic HCM phenotype, but standardized echocardiographic criteria for identifying it remain limited. Peak Doppler gradients may underestimate obstruction when systolic cavity obliteration causes forward flow to cease. A midsystolic Doppler signal void has therefore been proposed as a flow-based marker of midapical obstruction.

Data Highlights

• The study included 606 consecutive patients with HCM.

• A midsystolic Doppler signal void was present in 142 patients (23.4%).

• Apical aneurysm occurred in 33.8% of patients with signal void versus 8.2% without it.

• Among patients with signal void, 14.1% had midapical Doppler gradients below 30 mm Hg.

• Apical aneurysm and lower absolute global longitudinal strain were independently associated with signal void.

Key Findings

• Signal void was associated with pronounced midapical and papillary muscle hypertrophy, smaller indexed left ventricular end-diastolic volumes, and higher midapical Doppler gradients.

• Patients with signal void had lower absolute global longitudinal strain, higher cardiac troponin I levels, and more apical aneurysms.

• Peak Doppler gradients may underestimate midapical obstruction when systolic flow cessation prevents reliable gradient measurement.

• Signal void identified a distinct midapical HCM phenotype not fully reflected by gradient-based assessment alone.

• Longitudinal clinical outcomes were not evaluated, so diagnostic and prognostic value requires prospective validation.

Clinical Implications

A reproducible midsystolic Doppler signal void may complement conventional gradient measurements when assessing suspected midapical obstruction. Its presence may prompt targeted evaluation of ventricular morphology, myocardial deformation, and apical aneurysm, but the study does not establish that using this marker improves clinical outcomes.

Conclusion

Systolic cavity obliteration manifested as a midsystolic Doppler signal void identifies a distinct midapical HCM phenotype associated with regional hypertrophy, smaller cavity size, impaired longitudinal deformation, elevated cardiac troponin I, and a higher prevalence of apical aneurysm.

Related Resources & Content

1. Midsystolic Doppler Signal Void Identifies Midapical Obstruction in Hypertrophic Cardiomyopathy — Authors: Zhenzhen Wang, Wei Liu, Wei Li, Wensheng Tao, Jiayi Chen, Wenxiu Ye, Zhiqiang Dong, Shuwei Wang, Bing Zhou, Meijuan Yan, and Yong Cui; Publication: Journal of the American Society of Echocardiography; Date published: July 2026 (online March 16, 2026).

2. Supplementary material accompanying Midsystolic Doppler Signal Void Identifies Midapical Obstruction in Hypertrophic Cardiomyopathy — Authors: Zhenzhen Wang, Wei Liu, Wei Li, Wensheng Tao, Jiayi Chen, Wenxiu Ye, Zhiqiang Dong, Shuwei Wang, Bing Zhou, Meijuan Yan, and Yong Cui; Publication: Journal of the American Society of Echocardiography; Date published: July 2026 (online with the article March 16, 2026).

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