Apical HCM

Summary

An 80 year old male presented following an episode of loss of consciousness which occurred during the night whilst passing urine. He was brought to the emergency department by which time he had made a full recovery. Physical examination was unremarkable, however, on palpation of  the carotid pulses he developed a short episode of asystole which led to further brief loss of consciousness. 12 lead ECG was grossly  abnormal with widespread T wave inversion and voltage criteria for left ventricular hypertrophy.

This gentleman had been seen ten years earlier for investigation of atypical chest pain with normal coronaries on angiography. His ECG was abnormal at that stage but had been attributed to a previous heart attack despite no clear wall motion abnormality on echo. There was no family history of cardiac disease.

An echocardiogram was repeated on this admission and was technically difficult with poor visualisation of the apex (image 1,2).

 

 

 

 

 

 

There was, however, a suggestion of localised hypertrophy in the apical lateral segments. The image quality was greatly enhanced using Sonovue contrast (images 3-5).

 

 

 

 

 

 

 

This confirmed the clinical diagnosis of apical hypertrophic cardiomyopathy. He was assessed by the electrophysiololgists with a  view to pacing and offered screening for his first degree relatives.

Learning point

It is always important to integrate all of the available clinical information. In this case the gross ECG abnormalities were difficult to explain by coronary artery disease and therefore detailed analysis of cardiac structure was particularly important. Transpulmonary contrast can be very helpful at improving endocardial definition in such a case.

Last Updated (Tue 28 May 2013)

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