Severe Valvular Aortic Stenosis and Fixed Subvalvular Aortic Stenosis: A Rare and Challenging Combination

A 58-year-old man with a history of hypertension presented with accelerating angina. Transthoracic echocardiography revealed a thickened aortic valve with pressure gradients and an estimated aortic valve area suggestive of mild aortic stenosis. Left heart catheterization demonstrated non-significant coronary artery disease. Pressure tracings showed a high left ventricular pressure and a mean gradient across the aortic valve of 69 mmHg. Subsequent transesophageal echocardiography revealed a subvalvular aortic stenosis that was secondary to the subaortic membrane, with severe valvular aortic stenosis. The patient underwent surgical resection of the subaortic membrane followed by bioprosthetic aortic valve replacement, with resolution of his symptoms. Video 1: Transesophageal echocardiography, five-chamber view, showing the calcified aortic valve and subaortic membrane. Video 2: Transesophageal echocardiography, long-axis view, showing aliasing of the aortic flow at valvular and subvalvular levels.