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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.

Utility of tissue characterization in apical hypertrophic cardiomyopathy diagnosis