79 year-old male with known hypertrophic obstructive cardiomyopathy (HOCM) with progressive exertional dyspnea NYHA CCS Class IIII and mild inferior wall ischemia on stress MPI. Echo revealed asymmetric septal hypertrophy (with septal thickness of 21mm) and systolic anterior motion (SAM) of anterior mitral valve leaflet, high LVOT gradient (rest gradient = 42mmHg; peak stress and Valsalva gradient = 141mmHg) hyperdynamic LV function (70%) and mild to moderate MR. MRI confirmed echo findings and also revealed systolic obliteration of LV cavity with scattered patchy minimal necrosis. Cardiac cath revealed 88 mmHg gradient at rest at mid cavity level with positive Brockenbrough-Braunwald-Morrow sign with gradient of 190 mmHg and moderate mid LAD lesion. Patient remains symptomatic despite being on maximum tolerated dose of calcium channel blocker (& is intolerant to beta blocker). Patient is now planned for echo guided alcohol septal ablation (ASA) for refracting symptomatic HOCM.