Multimodality Imaging in Apical Hypertrophic Cardiomyopathy: Can Echocardiography Learn from Cardiac Magnetic Resonance?

Apical hypertrophic cardiomyopathy is a distinctive and often under-recognized variant of hypertrophic cardiomyopathy, characterized by predominant thickening of the apical segments of the left ventricle. Echocardiography and cardiac magnetic resonance imaging represent the two principal modalities for diagnosis and morphological assessment. While transthoracic echocardiography remains the first-line imaging technique, it may underestimate apical involvement, particularly when image foreshortening or poor endocardial/epicardial delineation occurs. Cardiac magnetic resonance has become the reference standard for defining apical morphology, quantifying hypertrophy, and characterizing myocardial tissue and perfusion. Beyond its diagnostic role, magnetic resonance serves as a research platform for the identification of new apical-centric criteria which, after appropriate validation, may be translated into echocardiographic practice. Echocardiography, however, retains unique strengths through its real-time evaluation of cardiac dynamics, ready-to-use approach to diastolic function assessment, and its ability to identify subtle apical or para-apical obstructive gradients that may raise the initial diagnostic suspicion. This review underscores the complementary roles of the two modalities and the multiple domains in which transthoracic echocardiography can derive substantial methodological and conceptual benefit from cardiac magnetic resonance imaging, both in imaging methodology and in the refinement of diagnostic evaluation.