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in the 1960s. This sign is characterized by a decrease in arterial pulse pressure after a premature ventricular contraction (PVC), accompanied by a significant increase in peak left ventricular (LV) systolic pressure. In patients without dynamic outflow obstruction, the longer filling period after a PVC increases LV end-diastolic volume; this and postextrasystolic potentiation increase both stroke volume and arterial pulse pressure.
In patients with obstructive HCM, provocation with a PVC leads to a paradoxic decrease in pulse pressure. Maneuvers to elicit the Brockenbrough-Braunwald-Morrow sign are frequently used to establish the diagnosis of obstructive HCM during cardiac catheterization and to assess the adequacy of septal reduction after surgical myectomy or alcohol septal ablation.
Figure 1 illustrates the Brockenbrough-Braunwald-Morrow sign in a 65-year-old man with obstructive HCM before and after transaortic septal myectomy. For comparison, we present intraoperative pressure tracings from 2 patients with fixed LV outflow tract obstruction. The patient in Figure 2 is a 69-year-old man with aortic valvular stenosis, and Figure 3 shows pressure tracings from a 64-year-old woman with membranous and tunnel subaortic stenosis not associated with systolic anterior motion of the mitral valve.
At operation, LV and aortic pressures were simultaneously traced with high-fidelity catheters before and after cardiopulmonary bypass. We observed the Brockenbrough-Braunwald-Morrow sign in the patient with obstructive HCM (Figure 1, A), with a significant decrease in arterial pulse pressure after a PVC. The sign disappeared after septal myectomy, and pulse pressure remained stable after provocation (Figure 1, B). In the 2 patients with aortic stenosis and subvalvular stenosis (Figures 2 and 3), prebypass arterial pulse pressure did not change after PVC. As expected, the Brockenbrough-Braunwald-Morrow sign could not be elicited in these patients.
A hemodynamic technic for the detection of hypertrophic subaortic stenosis.
Teaching the skill of observation is often shortchanged in medical education.1 As William Osler famously noted, the whole art of medicine is in observation. In this issue of the Journal, Cui and colleagues2 from the Mayo Clinic provide an example of how the power of a simple observation can have enduring educational value in our approach to diagnosis and management of human disease. The Brockenbrough-Braunwald-Morrow sign was first described in 1961 by the eponymous clinicians3 in patients presenting with dynamic left ventricular outflow tract obstruction and is characterized by a decrease in arterial pulse after a premature ventricular contraction, along with a significant increase in peak left ventricular systolic pressure.