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34 reviewsBSTRACT2 Background: Left ventricular mid-ventricular obstruction (MVO) is thought to be dynamic 3 with hypertrophic cardiomyopathy (HCM). Therefore, the distance between the anterior 4 papillary muscle and interventricular septum was employed as a parameter named APM-IVS 5 distance for assessing MVO by rest echocardiography. 6 Methods: MVO was defined as a mid-ventricular gradient of ≥ 30 mmHg at rest or after being 7 provoked. APM-IVS distance was analyzed on apical three chamber view at end-diastole. 8 Results: A total of 2125 patients with HCM were enrolled in this study. Among these, data 9 from 1453 patients with measurable APM-IVS distances were analyzed. Of the 1453 patients, 10 596 had MVO, while 857 did not exhibit MVO. Multivariate logistic regression analyses 11 showed that APM-IVS distance was an independent indicator of MVO (adjusted odds ratio [95% 12 confidence interval (CI)]: 0.487 [0.448–0.529]). The APM-IVS distance demonstrated the 13 highest diagnostic accuracy in identifying MVO, exhibiting an area under the receiver 14 operating characteristic curve of 0.949 (95% CI: 0.937–0.960). The presence of a smaller APM15 IVS distance was correlated with increased incidence of left ventricular apical aneurysm and 16 MVO, elevated levels of N-terminal pro brain natriuretic peptide, as well as higher New York 17 Heart Association functional class. Among those with MVO, 198 patients underwent surgical 18 myectomy and were followed up after a median time of 12 months. APM-IVS distance19 increased from 7.6±2.2 mm to 18.9±4.9 mm, and the peak mid-ventricular gradient decreased20 from 50 mm Hg (36–57 mmHg) to 3 mmHg (3–7 mmHg) at follow-up. 21 Conclusions: A small APM-IVS distance was associated with MVO, which was alleviated 22 after myectomy following an increase in APM-IVS distance.23 KEYWORDS: Hypertrophic Cardiomyopathy; Mid-ventricular Obstruction; Papillary 24 Muscle; Interventricular septum; Echocardiography 25 ABBREVIATIONS LIST