Can an hourglass appearance of the left ventricle in apical cardiomyopathy be mistaken for an apical aneurysm, especially if the apical aneurysm has a thick wall?

Differentiating Apical Hypertrophic Cardiomyopathy from Apical Aneurysm

Yes, an hourglass appearance of the left ventricle in apical cardiomyopathy can be mistaken for an apical aneurysm, especially when the apical aneurysm has a thick wall. 1

Diagnostic Challenges

• Conventional echocardiography may have limitations in accurately visualizing the apex of the left ventricle, leading to potential misdiagnosis between apical hypertrophic cardiomyopathy (ApHCM) and apical aneurysm 1
• The hourglass configuration seen in ApHCM can mimic the appearance of an apical aneurysm, particularly when the aneurysm has thickened walls 1, 2
• Sustained cavity obliteration in ApHCM can lead to development of true apical aneurysms, further complicating the distinction 3
• ECG findings can be misleading, as both conditions may present with deep T-wave inversions in precordial leads 4, 5

Diagnostic Approach

Imaging Modalities

• Cardiovascular Magnetic Resonance (CMR) is the gold standard for differentiating between these conditions due to its superior spatial resolution and tissue characterization capabilities 1

• CMR can more accurately detect:

  • True apical aneurysms (particularly when small) 1
  • Precise distribution of apical hypertrophy 1
  • Presence of late gadolinium enhancement (LGE) indicating myocardial fibrosis 1

• Contrast-enhanced echocardiography may be reasonable when CMR is unavailable or contraindicated 1

Key Differentiating Features

• Apical aneurysm characteristics:

  • Discrete thin-walled dyskinetic or akinetic segment 1
  • Transmural scar or LGE of the most distal portion of the LV chamber 1
  • Often associated with systolic dysfunction 1

• ApHCM characteristics:

  • Predominant hypertrophy of the distal LV wall 4
  • Spade-like configuration of the LV at end-systole 2
  • Sustained cavity obliteration in the apical portion 3

Clinical Implications

• Accurate differentiation is crucial as management strategies differ:

  • Apical aneurysm is associated with higher risk of sudden cardiac death, requiring consideration for ICD placement 1
  • Apical aneurysm increases risk for thromboembolic events, potentially warranting anticoagulation 6
  • Misdiagnosis may lead to inappropriate risk stratification and treatment decisions 1

• Patients with ApHCM who have severe cavity obliteration are at higher risk of developing true apical aneurysms, requiring closer monitoring 3

Pitfalls to Avoid

• Relying solely on echocardiography for definitive diagnosis, especially with suboptimal acoustic windows 1
• Failing to recognize that both conditions can coexist - ApHCM can evolve to develop a true apical aneurysm 2, 3
• Overlooking ECG changes that may simulate coronary artery disease patterns 5
• Missing small apical aneurysms that may be difficult to visualize with conventional imaging 1

When diagnostic uncertainty persists, CMR imaging should be performed to definitively distinguish between these entities, as it provides superior visualization of the LV apex and can characterize tissue properties through late gadolinium enhancement 1.