Quick Fire Cases
Felipe Soares Torres, MD, PhD
Assistant Professor
University of Toronto / University Medical Imaging Toronto, Canada
Felipe Soares Torres, MD, PhD
Assistant Professor
University of Toronto / University Medical Imaging Toronto, Canada
Felipe Sanchez Tijmes, MD
Staff
University Health Network, University of Toronto
Clinica Santa Maria, Canada
Kate Hanneman, MD MPH
Associate Professor
University of Toronto
University of Toronto, Canada
Elsie T. Nguyen, MD, FRCPC
Associate Professor of Radiology
Department of Medical Imaging, University of Toronto, Canada
60 y.o. female with hypertrophic cardiomyopathy (HCM) and small apical aneurysm identified on echocardiography referred for cardiac MRI evaluation.
Diagnostic Techniques and Their Most Important Findings:
Cardiac MRI performed using a 1.5T magnet revealed an apical HCM phenotype with a maximum end-diastolic wall thickness of 21 mm and mid to distal apical cavity obliteration during systole. There was a small residual pool of contrast in the apical cavity at end-systole (Figure 1) which was not seen on a prior MRI performed 4 years earlier. No late gadolinium enhancement was identified. Prior contrast echocardiography has characterized this slit as a small apical aneurysm.
The development of an aneurysm in apical HCM may follow a predictable pattern, from an early slit pool of contrast in end-systole to a full blown dyskinetic outpouching with transmural LGE. Apical aneurysms are associated with adverse events and hence accurate and reproducible assessment by CMR is needed. The literature provides different definitions on what constitutes an apical aneurysm, particularly when using CMR imaging (Table). For the purpose of risk stratification, on the other hand, the 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy defines an apical aneurysm as a discrete thin-walled dyskinetic or akinetic segment with transmural scar or LGE of the most distal portion of the left ventricular chamber, independent on size. The differences in the definition of an apical aneurysm in patients with HCM and its relation to what constitutes a risk factor may create problems when comparing results from different modalities (such as echocardiography and CMR) and could be, in part, responsible for the discrepancy seen in the detection rate between modalities and within modalities.
Learning Points from this Case: Apical aneurysms are not infrequent in patients with apical HCM, but the true prevalence may depend on the definition used. Variability in the definition of what constitutes an apical aneurysm creates challenges for consistent and reproducible detection, communication between modalities and may pose challenges for risk stratification of patients with apical HCM.
