Complete resolution of apical hypertrophy and fibrosis: the role of serial cardiovascular magnetic resonance tissue characterization to differentiate hypertrophic cardiomyopathy from myocarditis

A 71-year-old female with Type 2 diabetes mellitus, hypertension, and hypercholesterolaemia presented to the emergency department with a 2-day history of heavy chest pain radiating to the left shoulder. Electrocardiogram showed normal sinus rhythm with no evidence of ischaemia, but serial Troponin T levels were elevated (301 and 233 ng/L, normal <14 ng/L). Acute coronary syndrome management was initiated. Invasive angiography showed left ventricular (LV) apical akinesia (Panel A) with only mild coronary atheroma. Echocardiography showed a non-dilated LV with apical hypertrophy, chordal systolic anterior motion, and outflow tract obstruction (peak gradient 56 mmHg). The mid to apical LV segments were akinetic and systolic function impaired (ejection fraction of 40–45%). The patient was medically managed with dual antiplatelet therapy and secondary preventative medication. Outpatient cardiac magnetic resonance (CMR) imaging 1 month later revealed apical LV hypertrophy (Panel B) with mid to apical LV systolic cavity obliteration (see Supplementary material online, Video S1). Myocardial T2 and T1 were elevated in the mid to apical hypertrophied segments suggestive of oedema and fibrosis (Panels C–E). Late gadolinium enhancement imaging showed corresponding patchy focal fibrosis, but no evidence of myocardial infarction (Panel F). Based on these findings, apical hypertrophic cardiomyopathy (HCM) was suspected. Repeat CMR at 1 year revealed full resolution with no LV hypertrophy or cavity obliteration (see Supplementary material online, Video S2). Fibrosis was no longer seen (Panels G–I) in keeping with resolved myocarditis rather than HCM. Serial CMR imaging provided important information on inflammation and scarring, helping to distinguish inflammatory heart disease from HCM and thus guide appropriate management. Supplementary material is available at European Heart Journal online.