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Nat. Rev. Cardiol. doi:10.1038/nrcardio.2016.98 Figure 2 Left ventricular ejection velocities in early systole and mid-systole in obstructive HCM Figure 2 | Left ventricular ejection velocities in early systole and mid-systole in obstructive HCM. a | Early systole before mitral–septal contact. Pulsed Doppler at entrance of left ventricular outflow tract. Mid and late systole is shaded on the second trace. Early systolic unobstructed flow occurs before mitral–septal contact (arrows). b | Before mitral–septal contact, flow courses around the septum and catches the anteriorly displaced mitral valve and sweeps it into the septum. The chordae and papillary muscles act to posteriorly restrain the mitral valve. c | After mitral–septal contact. Early systole is shaded on the second trace. The beginning of the mid-systolic drop occurs at the onset of mitral–septal contact, and the abrupt increase in afterload. The nadir of the drop occurs simultaneously with the peak of the continuous wave Doppler gradient and peak afterload (arrow)46,48. d | The mid-systolic drop is caused by afterload mismatch between the impedance of obstruction and left ventricular contractility. Panels a and c reprinted from Halpern, D. G. & Sherrid, M. V. in Comprehensive Textbook of Echocardiography Ch. 5 (ed. Nanda, N. C.) 1348–1368 (Jaypee Brothers Medical Publishers, 2013). Panels a and c reprinted from Halpern, D. G. & Sherrid, M. V. in Comprehensive Textbook of Echocardiography Ch. 5 (ed. Nanda, N. C.) 1348–1368 (Jaypee Brothers Medical Publishers, 2013). Ormerod, J. O. M. et al. (2016) Myocardial energy depletion and dynamic systolic dysfunction in hypertrophic cardiomyopathy Nat. Rev. Cardiol. doi:10.1038/nrcardio.2016.98