Detection of apical hypertrophic cardiomyopathy by cardiovascular magnetic resonance in patients with non-diagnostic echocardiography

Cardiac magnetic resonance in hypertrophic cardiomyopathy: current state of the art

Hypertrophic cardiomyopathy is a complex disorder with significant heterogeneity in clinical characteristics and natural history. Traditionally, the diagnosis has been based on clinical assessment and echocardiography; however, persistent challenges in its noninvasive evaluation remain. Hence, improved diagnostic techniques could lead to better risk stratification of patients, which would potentially identify patients likely to benefit from effective therapies. Recent studies have demonstrated the increasing utility of cardiac magnetic resonance in the management of this disease. With the increasing utilization of genetics, cardiac magnetic resonance is likely to play an even more important role in discerning the subtle morphologic differences seen in such patients with similar genotypic profiles.

Unusual features of apical hypertrophic cardiomyopathy

Apical hypertrophic cardiomyopathy (HC) is commonly regarded as a relatively benign condition of young to middle-aged Japanese men. Apical HC in a predominantly Caucasian population is not well characterized. The cardiovascular characteristics, morbidity, and mortality of a series of elderly, predominantly Caucasian subjects with apical HC are described. Thirty-two consecutive patients with apical HC (mean age 71 years, 15 men) were identified from a teaching hospital without a specialized HC clinic. Twenty-three subjects were Caucasian, 8 were Asian, and none Japanese. Twenty-two patients had coexistent hypertension. Six patients had documented late evolution of apical HC on electrocardiography and echocardiography up to 5 years after previous documented normal left ventricular morphology on echocardiography. The diagnosis of apical HC was initially missed in 7 patients because of inadequate image quality of the left ventricular apex and a lack of awareness of the condition. The correct diagnosis was assigned to all 7 patients after repeat echocardiography. Six of 13 patients who underwent coronary angiography had associated coronary artery fistulae. One patient required an implantable defibrillator for exertional syncope. Ten of the patients developed atrial fibrillation, 6 of whom had complicating thromboembolic events. Of the 6 deaths in the cohort, 2 followed atrial fibrillation-related hemiplegic strokes, and 2 followed progressive heart failure. In conclusion, apical HC in a teaching hospital without a specialized HC clinic and in a predominantly Caucasian population is a disease of the elderly. Documented late morphologic evolution is not uncommon, with a high incidence of coronary fistulae and morbid atrial fibrillation.

Assessing myocardial bridging and left ventricular configuration by 64-slice computed tomography in patients with apical hypertrophic cardiomyopathy presenting with chest pain

OBJECTIVE

We aimed to assess the usefulness of multislice computed tomographic (CT) angiography to detect coronary artery disease (CAD), including myocardial bridging (MB) and left ventricular morphology (LVG), in patients with apical hypertrophic cardiomyopathy (AHCM) who presented with angina and apical asynergy.

MATERIALS AND METHODS

Sixty-four-slice CT angiography was performed in 14 patients with echocardiographically diagnosed AHCM who presented with typical or atypical chest pain. Coronary angiography was performed in 7 patients because of either suspected CAD or echocardiographic apical hypokinesia. We assessed the correlations between coronary anatomy, apical thickness, and LV configuration that were determined by echocardiography, LVG, and 64-slice CT angiography.

RESULTS

The multislice CT confirmed the diagnosis of AHCM in 14 patients. The LVGs were all compatible between the 64-slice CT angiography and the LVG in the 7 patients who had "ace-of-spades" configurations, apical sequestrations, and an apical aneurysm. Furthermore, 2 significant CADs and 7 MBs were detected by 64-slice CT angiography.

CONCLUSIONS

Multislice CT can offer high accuracy for the noninvasive detection of apical wall thickness and left ventricular configuration in patients with AHCM. It also provides additional information about significant coronary stenosis and MB in patients with chest pain. This promising technology has a potential to complement invasive cardiac catheterization in clinical practice.

Effects of somatostatin analogues on acromegalic cardiomyopathy: results from a prospective study using cardiac magnetic resonance

OBJECTIVE

Left ventricular (LV) hypertrophy is the main finding of patients with active acromegaly at cardiac magnetic resonance (CMR). The aim of the study was to evaluate heart changes in acromegalic patients treated with somatostatin analogues (SMSA) using CMR.

DESIGN AND PATIENTS

This was a prospective study. Fourteen consecutive patients (8 women, mean age 46+/-10 yr) with untreated active acromegaly were submitted to CMR and 2D-color Doppler echocardiography before and after a 6-month SMSA course.

MEASUREMENTS

LV volume, mass (LVM) and wall thickness.

RESULTS

CMR: Mean LVM and LVM index (i) decreased from 151+/-17 g and 77+/-9 g/m2, to 144+/-24 g and 70+/-12 g/m2, respectively (p=0.047 and p<0.0001, respectively); LV hypertrophy reverted in 6 out of 10 patients (p=0.016). Systolic function, evaluated by measuring LV ejection fraction remained normal in all patients (67+/-11%). There was not a correlation between changes in LVMi and changes in serum IGF-I concentrations. However, patients with controlled disease had higher reduction of LVMi than those with uncontrolled acromegaly (DeltaLVMi, -8.2+/-4.2 vs 4.0+/-5.3 p<0.05). 2D-echo cardiography: Mean LVMi decreased from 110+/-24 g/m2 to 100+/-20 g/m2 (p=0.026); hypertrophy, revealed in 5 patients (36%) at baseline, reversed in 2 patients (p=0.500) after SMSA; abnormal diastolic function [evaluated by isovolumic relaxation time or early (E) to late of atrial (A) peak velocities ratio] found in 4 patients (29%) at the study entry, improved in a patient. Systolic function remained within the normal range in all patients during the study period.

CONCLUSIONS

CMR detects changes in LVMi in most patients with acromegaly treated with SMSA, which are more evident if the disease is controlled.

[Current indications for cardiac MR imaging]

MRI has acquired over the years a role in the evaluation of cardiovascular pathology especially with regards to its ability to assess right and left ventricular function and delayed postcontrast "viability" sequences. Current class I clinical indications include: viability for patients with ischemic cardiomyopathy and acute coronary syndrome, etiology and prognostic evaluation of non-ischemic cardiomyopathies including myocarditis and arrhytmogenic right ventricular cardiomyopathy, chronic pericarditis and cardiac masses, non-urgent aortic aneurysm and dissection, congenital cardiopathies: vascular malformations and follow-up after curative or palliative surgery. MRI provides a complete non operator dependent evaluation, and is particularly useful for follow-up since it may be repeated due to its absence of ionizing radiation

The role of cardiovascular magnetic resonance imaging in heart failure

Noninvasive imaging plays a central role in the diagnosis of heart failure, assessment of prognosis, and monitoring of therapy. Cardiovascular magnetic resonance (CMR) offers a comprehensive assessment of heart failure patients and is now the gold standard imaging technique to assess myocardial anatomy, regional and global function, and viability. Furthermore, it allows assessment of perfusion and acute tissue injury (edema and necrosis), whereas in nonischemic heart failure, fibrosis, infiltration, and iron overload can be detected. The information derived from CMR often reveals the underlying etiology of heart failure, and its high measurement accuracy makes it an ideal technique for monitoring disease progression and the effects of treatment. Evidence on the prognostic value of CMR-derived parameters in heart failure is rapidly emerging. This review summarizes the advantages of CMR for patients with heart failure and its important role in key areas.

Advances in Cardiovascular MRI for Diagnostics: Applications in Coronary Artery Disease and Cardiomyopathies

BACKGROUND: Cardiac magnetic resonance (CMR) imaging has emerged as an important cardiac imaging technique for the evaluation of multiple cardiac pathologies. OBJECTIVE/METHOD: The goal of this review is to describe recent advances in techniques which have extended the potential applications of CMR. The focus will be on the clinical applications of CMR for the evaluation of coronary artery disease and heart failure/cardiomyopathies which are major causes of morbidity and mortality worldwide. CONCLUSION: CMR provides unique tissue characterization which is not available from other imaging modalities and has demonstrated important diagnostic and prognostic information in many forms of heart disease.

Evolving anatomic, functional, and molecular imaging in the early detection and prognosis of hypertrophic cardiomyopathy

Evolving imaging modalities in hypertrophic cardiomyopathy (HCM), such as tissue Doppler, speckle tracking, measures of myocardial blood flow, and cardiac magnetic resonance with gadolinium enhancement, have advanced our understanding of the pathogenesis of myocardial dysfunction in hypertrophic cardiomyopathy. These modalities have the potential to differentiate HCM from other causes of left ventricular hypertrophy when there is uncertainty about the diagnosis and to identify affected individuals in the pre-clinical phase of the disease process. Furthermore, preliminary data suggests that functional imaging techniques may add incremental value to conventional risk stratification tools to identify individuals at high risk for sudden death or progression to congestive heart failure.

Risk stratification for therapeutic management and prognosis

In coronary artery disease (CAD), cardiac magnetic resonance (CMR) imaging can integrate several types of pulse-sequence examinations (eg, myocardial perfusion, cine wall motion, T2-weighted imaging for myocardial edema, late gadolinium enhancement, and CMR angiography) that can provide anatomic, functional, and physiologic information about the heart in a single imaging session. Because of this ability to interrogate myocardial physiology using different pulse sequence techniques within a single CMR session, this technique has been recognized increasingly in many centers as the test of choice for assessing patients who present with cardiomyopathy of undetermined cause. This article first reviews the current evidence supporting the prognosticating role of CMR in assessing CAD and then discusses CMR applications and prognostication in many non-coronary cardiac conditions.

Hypertrophic cardiomyopathy with midventricular obstruction and apical aneurysm formation in a single family: case report

Background

Hypertrophic cardiomyopathy (HCM) is an extremely heterogeneous disease. An under recognized and very often missed subgroup within this broad spectrum concerns patients with left ventricular (LV) apical aneurysms in the absence of coronary artery disease.

Case presentation

We describe a case of HCM with midventricular obstruction and apical aneurysm formation in 3 patients coming from a single family. This HCM pattern was detected by 2D-echocardiography and confirmed by cardiac magnetic resonance imaging. A cardioverter defibrillator was implanted in one of the patients because of non-sustained ventricular tachycardia detected in 24-h Holter monitoring and an abrupt drop in systolic blood pressure during maximal exercise test. The defibrillator activated 8 months after implantation by suppression of a ventricular tachycardia providing anti-tachycardia pacing. The patient died due to refractory heart failure 2 years after initial evaluation. The rest of the patients are stable after a 2.5-y follow-up period.

Conclusion

The detection of apical aneurysm by echocardiography in HCM patients may be complicated. Ventricular tachycardia arising from the scarred aneurysm wall may often occur predisposing to sudden death.

Cardiovascular magnetic resonance of cardiomyopathies

Cardiomyopathies are a heterogeneous group of diseases of the myocardium associated with architectural abnormalities and mechanical dysfunction. Recent advances in our understanding of the genetics, pathophysiology, and natural history of these conditions has resulted in better diagnosis and management, leading to improvements in mortality. Major developments in imaging techniques, in particular contrast-enhanced MRI, now permit in vivo tissue characterization of the myocardium. Through defining disease severity, etiology, and to some extent in risk stratification, routine cardiovascular magnetic resonance evaluation of this group of patients provides essential information required in everyday clinical practice.

Case report. Isolated left ventricular myocardium non-compaction: MR imaging findings from three cases

The purpose of this study is to report three cases of left ventricular myocardium non-compaction (LVNC), with emphasis on the MRI findings. From May 2006 to February 2007, three patients -- 2 females (6 years and 42 years of age) and 1 male (18 years of age) -- presented to our radiology department, two of them with fatigue, shortness of breath and episodes of syncope and arrhythmia, for further investigation by cardiac MRI because an apparent asymmetrical pattern of hypertrophy of the left ventricular myocardium was suspected by transthoracic echocardiography. The 18-year-old patient was only experiencing arrhythmia, and arrhythmogenic right ventricular dysplasia was suspected. The images (produced by a 1.5T MRI system) were interpreted by two experienced radiologists and post-processed with Argus software (Siemens, Germany) for ejection fraction calculation. In all three patients, MRI aided in the correct identification of prominent ventricular myocardial trabeculations and deep intertrabecular recesses communicating with the ventricular cavity, as well as areas of hypokinesia with depressed systolic function, and showed the absence of myocardial delayed enhancement and other structural heart defects. In conclusion, cardiac MRI was useful for correctly identifying this rare congenital heart disorder and appears to increase diagnostic accuracy. Although considered a rare anomaly, radiologists should be capable of recognizing LVNC, as current non-invasive imaging methods have increased the frequency of this diagnosis and timely detection is vital in considering early-stage transplantation.

Left ventricular hypertrophy in athletes

Participation in regular intensive exercise is associated with a modest increase in left ventricular wall thickness (LVWT) and cavity size. The magnitude of these physiological changes is predominantly determined by a variety of demographic factors which include age, gender, size, ethnicity, and sporting discipline. A small minority of male athletes participating in sporting disciplines involving intensive isotonic and isometric exercise may exhibit substantial increases in cardiac size that overlap with the phenotypic manifestation of the cardiomyopathies. The most challenging clinical dilemma incorporates the differentiation between physiological left ventricular hypertrophy (LVH) (athlete's heart) and hypertrophic cardiomyopathy (HCM), which is recognized as the commonest cause of non-traumatic exercise related sudden cardiac death in young (<35 years old) athletes. This review aims to highlight the distribution and physiological upper limits of LVWT in athletes, determinants of LVH in athletes, and echocardiographic methods of differentiating athlete's heart from HCM.

Applications of cardiac magnetic resonance in electrophysiology

Contemporary methods for evaluation and treatment of arrhythmia are increasingly dependent upon characterization of the underlying myocardial substrate. Cardiovascular magnetic resonance offers unsurpassed soft tissue resolution capable of visualizing detailed cardiac anatomic features and intra-myocardial barriers to conduction. Non-invasive visualization of such anatomic detail has the potential to improve methods to diagnose, risk stratify, and treat patients with arrhythmia. This review describes a brief overview of the current knowledge on the applications of cardiac magnetic resonance for evaluation and treatment of patients with arrhythmia.

Frequency and distribution of late gadolinium enhancement in magnetic resonance imaging of patients with apical hypertrophic cardiomyopathy and patients with asymmetrical hypertrophic cardiomyopathy: a comparative study

Our aim was to compare the frequency and distribution of late gadolinium enhancement (LGE) on contrast MRI between hypertrophic cardiomyopathy (HCM) patients with apical hypertrophic cardiomyopathy (APH) and those with asymmetrical septal hypertrophy (ASH). We studied 66 patients with HCM (50 men and 16 women; average age: 58.8 +/- 29.8 years) who had undergone MRI. All the MRI examinations were performed using a 1.5 T system. LGE images were acquired using the inversion recovery segmented spoiled-gradient echo and phase-sensitive inversion recovery methods. We evaluated 17 segments of the left ventricle as defined by the American Heart Association criteria for LGE determination. LGE was detected at the junction of the right ventricle and the interventricular septum in 25 (73.5%) of the 34 HCM patients with ASH and in the apex of the heart in 13 (40.6%) of the 32 patients with APH. LGE-positive areas were more widely distributed in the case of the ASH group than in the case of the APH group. The distribution of LGE was clearly different between the two groups (Fisher's exact probability test, P = 0.0068). The number of LGE-positive cases and LGE-positive segments were significantly higher in the ASH group than in the APH group and there was a significant difference in the distribution of the LGE-positive areas between the two groups. LGE was mainly detected in the hypertrophied areas of the myocardium.

Delayed enhancement on cardiac magnetic resonance and clinical, morphological, and electrocardiographical features in hypertrophic cardiomyopathy

BACKGROUND

The clinical, morphological, and electrocardiographical relevance of delayed enhancement (DE) in cardiac magnetic resonance (CMR) was studied in patients with hypertrophic cardiomyopathy (HCM).

METHODS AND RESULTS

A total of 56 patients underwent both gadolinium-enhanced CMR and 12-lead electrocardiogram. The CMR demonstrated DE at the left ventricular (LV) wall in 39 patients. The patients with DE included more cases with dilated phase of HCM, higher New York Heart Association (NYHA) classes and incidence of ventricular tachyarrhythmias (VT), lower LV ejection fraction (LVEF) and mean LV wall thickness (WT), and a larger ratio of maximum to minimum LVWT. The QRS duration was prolonged and the QRS axis deviated toward left with increases in the DE volume (r = 0.58 and r = 0.41, P < .01). Abnormal Q waves were present in 5 patients and the location coincided with the DE segments in 4 patients, but the concordance was not significant. The amplitude of T waves correlated with the ratio of the apex to basal LVWT (r = 0.38, P < .01) and was more negative in cases with DE at the apex.

CONCLUSIONS

In HCM, the DE was associated with higher NYHA classes and prevalence of VT, impaired global LV function and asymmetrical hypertrophy, and conduction disturbance, abnormal Q waves, and giant negative T waves.

The emerging role of cardiovascular magnetic resonance in refining the diagnosis of hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is a genetically and phenotypically diverse disease with some patients at risk of sudden death or heart failure. Maron et al. used cardiovascular magnetic resonance, in a specialist clinic setting, to identify a cohort of HCM patients with left ventricular apical aneurysms that were not detected by conventional echocardiography. Apical aneurysms were variable in morphology and associated with scarring, thrombus, and the occurrence of monomorphic ventricular tachycardia. Preliminary follow-up data indicate that they could be associated with poor medium-term outcome. The paper by Maron et al. continues the gradual evolution of our understanding of HCM, highlighting an important clinical subset of patients and a phenotypic feature of HCM. The study also identifies cardiovascular magnetic resonance as an important technique for phenotyping cardiac diseases, identifying prognostically important features, and highlighting pathophysiological mechanisms.

Practical applications of cardiovascular magnetic resonance

Recent developments in magnetic resonance imaging have focused attention on evaluation of patients with cardiac disease. These improvements have been substantiated by a large and expanding body of clinical evidence, making cardiovascular magnetic resonance the imaging modality of choice in a wide variety of cardiovascular disorders. A brief review on the current applications of cardiovascular magnetic resonance is provided, with reference to some of the most relevant studies, statements and reviews published in this field.

Role of cardiac magnetic resonance imaging in assessment of nonischemic cardiomyopathies

Diagnosis of nonischemic cardiomyopathy is a challenging process that influences patient morbidity and mortality. Currently, the well known World Health Organization classification has been revisited by an American Heart Association expert consensus panel. The contemporary classification is compatible with the rapid evolution in molecular genetics and evolving diagnostic tools such as cardiac magnetic resonance imaging (MRI). Magnetic resonance imaging is a robust diagnostic tool that offers various techniques to assess the function, morphology, perfusion, and scarring of myocardial tissue thus providing better understanding of the underlying causes of nonischemic cardiomyopathies. In this review, we discuss the current role of cardiac MRI in the evaluation of nonischemic cardiomyopathy, in the context of the current American Heart Association classification of these disorders.

Prevalence, clinical significance, and natural history of left ventricular apical aneurysms in hypertrophic cardiomyopathy

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is the most common genetic heart disease characterized by a diverse clinical and phenotypic spectrum. This study reports the prevalence, morphology, clinical course, and management of an underrecognized subgroup of HCM patients with left ventricular apical aneurysms.

METHODS AND RESULTS

Of 1299 HCM patients, 28 (2%) were identified with left ventricular apical aneurysms, including a pair of identical twins. Aneurysms were recognized at a wide age range (26 to 83 years), including 12 patients (43%) who were <or=50 years of age. Apical aneurysms varied considerably in size (maximum dimension, 10 to 66 mm), were dyskinetic/akinetic with thin rims, and were associated with transmural (and often more extensive) myocardial scarring identified by late gadolinium enhancement cardiovascular magnetic resonance. Apical aneurysms were recognized by echocardiography in only 16 of 28 patients (57%) but by cardiovascular magnetic resonance in the 12 patients undetected by echocardiography. Left ventricular chamber morphology varied; however, 19 patients (68%) showed an "hourglass" contour, with midventricular hypertrophy producing muscular narrowing and intracavitary gradients in 9 patients (74+/-42 mm Hg). Sarcomeric protein missense mutations known to cause other phenotypic expressions of HCM were present in 3 patients. Over 4.1+/-3.7 years of follow-up, 12 patients (43%) with left ventricular apical aneurysms experienced adverse disease complications (event rate, 10.5%/y), including sudden death, appropriate implantable cardioverter-defibrillator discharges, nonfatal thromboembolic stroke, and progressive heart failure and death.

CONCLUSIONS

Patients with left ventricular apical aneurysms represent an underappreciated subset in the heterogeneous HCM disease spectrum with important clinical implications, often requiring a high index of suspicion and cardiovascular magnetic resonance for identification. Apical aneurysms in HCM are associated with substantial cardiovascular morbidity and mortality and raise novel treatment considerations.

Utility of tissue characterization in apical hypertrophic cardiomyopathy diagnosis

A 60-year-old male with previous hypertension, left ventricle hypertrophy, and coronary artery disease was referred for stress echocardiography because of exertional chest pain. The electrocardiogram revealed deep T-wave inversion in the anterolateral leads. Contrast echocardiography was notable for an apical filling defect consistent with the apical form of hypertrophic cardiomyopathy. Cardiac magnetic resonance demonstrated the 'ace of spades' left ventricle cavity, confirming the diagnosis. Single photon emission computed tomography showed increased apical left ventricle tracer uptake. Velocity vector imaging study depicted lower than normal absolute maximal longitudinal tissue velocities. The apical longitudinal strain was negative without base to apex gradient. There were normal longitudinal strain values in the basal and mid myocardial segments (Figure 1). Apical hypertrophic cardiomyopathy is a rare condition occasionally missed by conventional echocardiographic studies. Intravenous contrast enhancement might improve diagnosis accuracy. Newer Doppler-based techniques allowing tissue characterization may complement contrast echocardiography in its diagnosis.

Apical Hypertrophic Cardiomyopathy Mimicking Acute Coronary Syndrome: A Case Report and Review of the Literature

Apical hypertrophic cardiomyopathy is a form of hypertrophic cardiomyopathy localized to the left ventricular apex. It is common in Japanese and other Asian populations, where it is generally considered relatively benign. However, its presence has also been recognized, though less commonly, in non-Asian patients. In these patients, the electrocardiographic changes and symptoms associated with apical hypertrophic cardiomyopathy often mimic acute coronary syndromes. Invasive or noninvasive evaluation of the left ventricular cavity confirms the diagnosis, with the “ace-of-spades” sign on left ventriculography being pathognomonic. Its prognosis is relatively benign in terms of cardiovascular mortality; however, morbid sequelae, such as diastolic dysfunction, left atrial enlargement, apical thrombi, ventricular aneurysms, and myocardial infarction, are not uncommon. The authors present a case of apical hypertrophic cardiomyopathy in a Caucasian patient who presented with findings suggestive of acute coronary syndrome and review the literature on apical hypertrophic cardiomyopathy.

High prevalence of cardiac hypertophy without detectable signs of fibrosis in patients with untreated active acromegaly: an in vivo study using magnetic resonance imaging

OBJECTIVE

Left ventricular (LV) hypertrophy and myocardial fibrosis are considered the main pathological features of acromegalic cardiomyopathy. The aim of the study was to evaluate the proportion of LV hypertrophy and the presence of fibrosis in acromegalic cardiomyopathy in vivo using cardiac magnetic resonance (CMR).

DESIGN AND PATIENTS

Fourteen consecutive patients (eight women, mean age 46 +/- 10 years) with untreated active acromegaly were submitted to two-dimensional (2D) colour Doppler and integrated backscatter (IBS) echocardiography and CMR.

MEASUREMENTS

LV volume, mass and wall thickness and myocardial tissue characterization (IBS and CMR).

RESULTS

On echocardiography: mean LV mass (LVM) and LVM index (LVMi) were 209 +/- 48 g and 110 +/- 24 g/m(2), respectively; hypertrophy was revealed in five patients (36%); abnormal diastolic function [evaluated by isovolumic relaxation time (IVRT) or early (E) to late or atrial (A) peak velocities (E/A ratio)] was found in four patients (29%). Systolic function evaluated by measuring LV ejection fraction (LVEF) was normal (mean 72 +/- 12%) in all patients. Six patients (43%) had increased IBS (mean 57.4 +/- 6.2%). On CMR: mean LVM and LVMi were 151 +/- 17 g and 76 +/- 9 g/m(2), respectively; 10 patients (72%) had LV hypertrophy. Contrastographic delayed hyperenhancement was absent in all patients; on the contrary, mild enhancement was revealed in one patient. Systolic function was normal in all patients (LVEF 67 +/- 11%). LVMi was not related to serum IGF-1 concentrations or the estimated duration of disease.

CONCLUSIONS

CMR is considered to be the gold standard for evaluating cardiac hypertrophy, fibrosis and systolic function. Using CMR, 72% patients with untreated active acromegaly had LV hypertrophy, which was only detected in 36% patients by echocardiography. However, cardiac fibrosis was absent in all patients irrespective of the estimated duration of disease. Although a very small increase in collagen content (as suggested by increased cardiac reflectivity at IBS), not detectable by CMR, could not be ruled out, it is unlikely that it would significantly affect cardiac function.

Apical hypertrophic cardiomyopathy in encephalomyopathy

Apical hypertrophic cardiomyopathy (AHC) is associated with neurological abnormalities such as transient ischemic attack, stroke, limb-girdle muscular dystrophy, or eosinophilic myositis in single cases. The association of AHC and metabolic myopathy has not been reported. In an 84-year-old woman with long-standing gait disturbance, dementia, Parkinson syndrome, ptosis, ophthalmoparesis, tetraparesis, polyneuropathy, lactacidosis, polyarthralgia, dorsalgia, and osteoporosis, cardiac examination for long-standing anginal chest pain and palpitations, revealed supraventricular and monomorphic ventricular ectopic beats, hypertrophic signs, ST-depression and negative T waves on electrocardiogram (ECG), diastolic dysfunction with impaired relaxation, and AHC on transthoracic echocardiography. AHC was confirmed by cardiac magnetic resonance imaging, which additionally showed a small left ventricular apical aneurysm with a wall-thickness of only 3 mm. The patient was suspected to additionally have a multisystem disease, most likely due to impaired oxidative metabolism. This case shows that AHC may take a mild course and be associated with a number of extracardiac abnormalities.

MRI of hypertrophic cardiomyopathy: part I, MRI appearances

OBJECTIVE

We present a two-part review about the use of MRI in patients with hypertrophic cardiomyopathy (HCM). This article, Part 1, focuses on the MRI appearances of HCM.

CONCLUSION

MRI has proven to be an important tool for the evaluation of patients suspected of having HCM because it can readily diagnose those with phenotypic expression of the disorder and can potentially identify the subset of patients at risk of sudden cardiac death.

Usefulness of delayed enhancement magnetic resonance imaging to differentiate dilated phase of hypertrophic cardiomyopathy and dilated cardiomyopathy

BACKGROUND

The dilated phase of hypertrophic cardiomyopathy (HCM) has a poor prognosis. For correct recognition of such patients, we compared the findings in cardiac delayed enhancement (DE)-magnetic resonance imaging (MRI) between HCM and dilated cardiomyopathy (DCM) patients.

METHODS AND RESULTS

Sixty-five patients (HCM 39, DCM 26) underwent gadolinium-DTPA-enhanced MRI. The HCM patients were divided into those with preserved (HCM-P, n = 30) and those with impaired systolic function (HCM-I, n = 9). DE-MRI demonstrated focal or diffuse DE at the left ventricular (LV) wall in 60% of HCM-P and 100% of HCM-I, but in only 12% of DCM. The DE distributed mainly septal to the anterior wall of LV, but the DE volume against whole LV muscle volume was much larger in HCM-I than in HCM-P and DCM (4.1 +/- 6.1% in HCM-P, 14.6 +/- 11.9% in HCM-I, and 0.8 +/- 2.4% in DCM, means +/- SD, P < .05). In HCM, there were weak but significant correlations between DE volume, and LV end-diastolic volume and LV end-systolic volume. In HCM-P, the percent of length shortening in the segments with DE was lower than that without DE.

CONCLUSIONS

The HCM patients had more DE than the DCM patients, and DE volume correlated to lower global and local LV function. DE-MRI may be useful to evaluate myocardial damage in HCM patients, and to differentiate the dilated phase of HCM from DCM.

MRI to assess arrhythmia and cardiomyopathies: relationship to echocardiography

Cardiomyopathies are a group of diseases that are associated with myocardial dysfunction and/or arrhythmia due to abnormalities of the myocardium. Echocardiography is the most commonly used method for functional evaluation and classification of cardiomyopathy since it is widely available. Magnetic resonance imaging (MRI) has recently emerged as a well-validated diagnostic tool for the understanding and treatment of these conditions. Morphological and functional information can be achieved with a high level of accuracy and reproducibility. This article reviews the applications of MRI in relationship to echocardiography for the diagnosis of cardiomyopathy and arrhythmogenic conditions of the heart.

Use of cardiovascular magnetic resonance for diagnosis and management in hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is an inherited cardiac disorder characterized by unexplained myocardial hypertrophy. The condition is associated with sudden cardiac death and is therefore often diagnosed postmortem, especially in the young and in competitive athletes. For this reason, intense research focuses on developing strategies to minimize this tragic consequence. Cardiovascular magnetic resonance (CMR) is a novel imaging modality that provides high-resolution images in an infinite number of planes with additional sequences that allows for tissue characterization and quantification of flow. The most exciting development is the application of late gadolinium-enhanced (LGE) imaging, which allows for in vivo detection of myocardial fibrosis. This review summarizes the current applications of CMR in HCM and also speculates on future applications, particularly the potential for risk stratification using LGE-CMR.

Hypertrophic cardiomyopathy mimicking acute myocardial infarction: diagnostic role of cardiac magnetic resonance

Rarely, hypertrophic cardiomyopathy can be associated with ST elevation on electrocardiogram. We report a rare case of anterior hypertrophic cardiomyopathy mimicking an acute myocardial infarction where the diagnosis of myocardial hypertrophy was made by cardiac magnetic resonance. The method was able to identify the myocardial hypertrophy located in basal segments of anterior wall respect to echocardiography.