An 85 year old female with glaucoma, asthma, depression and abnormal EKG (suspected of LVH strain). An echocardiography in 2013 showed normal systolic function with suspected apical hypertrophy. Referred to cardiac stress MRI to further evaluate ischemia and cardiomyopathy. MEDICATIONS: baclofen, alphagan, diltiazem, donezepil, ipatroprium, xalatan, levothyroxine, montelokast, omeprazole, sertraline, timolol, trospium Left VentricleThe left ventricle is mildly dilated with normal systolic function. The overall LV ejection fraction is 67%, the LV end diastolic volume index is 85 ml/m2 (normal range: 65+/-11), the LVEDV is 151 ml (normal range 109+/-23), the LV end systolic volume index is 28 ml/m2 (normal range 18+/-5), the LVESV is 49 ml (normal range 31+/-10), the LV mass index is 101 g/m2, and the LV mass is 179 g. There are no regional wall motion abnormalities present. The apex is severely hypertrophied with wall thickness measuring up to 22 mm; there is also extension of severe wall thickening into the basal and mid inferior, inferoseptal, and septal walls.First Pass PerfusionDuring hyperemia, a perfusion defect was present at the sub-endocardial level in the apical segments mainly in the septal and inferior walls.Viability/ Myocardial ScarThere was late gadolinium enhancement noted at the hypertrophied apex involving more than 50% in the anterior wall and less than 50% in the septum and lateral walls. The enhancement has an sub-endocardial and mid-myocardial pattern atypical for infarction. This finding in the context of a hypertrophied apex suggest fibrosis, inflammation, or infiltration. Left AtriumThe left atrium is mildly dilated. Right VentricleThe right ventricle is normal in size with normal systolic function. The overall RV ejection fraction is 52%, the RV end diastolic volume index is 68 ml/m2 (normal range 69+/-14), the RVEDV is 120 ml (normal range 110+/-24), the RV end systolic volume index is 33 ml/m2 (normal range 22+/-8), and the RVESV is 58 ml (normal range 35+/-13). Right AtriumThe right atrium is normal in size. Aortic ValveThe aortic valve opens widely and there is no significant aortic regurgitation.Mitral ValveThe mitral valve opens widely and there is no significant mitral regurgitation.Pulmonic ValveThe pulmonic valve opens widely. There is no significant pulmonic regurgitation.Tricuspid ValveThe tricuspid valve opens widely. There is no significant tricuspid regurgitation.AortaThe aortic root is mildly dilated (42 X 41mm). There is a left sided aortic arch with a normal brachiocephalic branching pattern.Pulmonary VeinsAll four pulmonary veins drain normally into the left atrium.Pulmonary ArteryThe main pulmonary artery is moderately dilated (46mm). Venous AnatomyThe SVC and IVC are normal in size and drain normally into the right atrium. PericardiumThere is mild pericardial effusion.Extracardiac FindingsThis study is not designed for the specific evaluation of extra-cardiac findings; therefore, the differentiation between artifacts and real extracardiac pathology may be difficult. If clinically indicated, a separate dedicated evaluation should be considered.
1. Normal LV size and systolic function (LVEF 67%).2. There is severe hypertrophy of the apex with cavity obliteration.3. Normal RV size and systolic function (RVEF 52%).4. During hyperemia, a perfusion defect was present at the sub-endocardial level in the apical segments mainly in the septal and inferior walls.5. There was late gadolinium enhancement noted at the hypertrophied apex involving more than 50% in the anterior wall and less than 50% in the septum and lateral walls. The enhancement has an sub-endocardial and mid-myocardial pattern atypical for infarction. This finding in the context of a hypertrophied apex suggest fibrosis, inflammation, or infiltration. 6. All these findings together are most probably compatible with apical hypertrophic cardiomyopathy. The perfusion defect is most probably secondary to the severe hypertrophy and not to coronary artery disease.7. The aortic root is mildly dilated.8. The pulmonary artery is moderately dilated.9. There is mild pericardial effusion.