Contrast-Enhanced Echocardiography for the Diagnosis of Apical Hypertrophic Cardiomyopathy George V. Moukarbel, M.D., Samir E. Alam, M.D., and Antoine B. Abchee, M.D. Department of Internal Medicine, American University of Beirut, Beirut, Lebanon The echocardiographic diagnosis of apical hypertrophic cardiomyopathy can be difficult in patients with poor acoustic windows. However, contrast-enhanced echocardiography can provide better im- ages in these patients and lead to the correct diagnosis. We present a patient with apical hypertrophic cardiomyopathy who was diagnosed using contrast-enhanced echocardiography. The use of contrast- enhanced echocardiography for the diagnosis of apical hypertrophic cardiomyopathy in patients with poor acoustic windows is discussed and the experience in the literature reviewed. (ECHOCARDIOG- RAPHY, Volume 22, November 2005) cardiomyopathy, contrast echocardiography, apical hypertrophic cardiomyopathy Hypertrophy of the apical myocardium is the characteristic feature of apical hypertrophic cardiomyopathy (AHC). This disorder is preva- lent in the Japanese population. The electro- cardiogram (ECG) of patients with AHC shows prominent T-wave inversions in the precordial leads. Definitive diagnosis is made by left ven- triculography demonstrating a spade-like ap- pearance. 1 Echocardiography has proven to be a helpful noninvasive tool to aid in the diagnosis. However, because of poor image quality in some patients, the condition can be missed by regular echocardiography. We describe a patient with AHC who was diagnosed by contrast-enhanced transthoracic echocardiography and review the present literature for similar cases. Case Report A 77-year-old lady was referred to the car- diology clinic for the investigation of dyspnea on exertion and an abnormal ECG. She had a negative past history for cardiac problems and there was no history of hypertension or dia- betes mellitus. Her physical examination was within normal limits. Her ECG showed large symmetric T-wave inversions in the precordial leads (Fig. 1). A transthoracic echocardiogram Address for correspondence and reprint requests: Antoine B. Abchee, M.D., F.A.C.C., Division of Cardiology, Depart- ment of Internal Medicine, American University of Beirut, P.O. Box 11-0236, Beirut, Lebanon. Fax: +9611744464; E-mail: aa14@aub.edu.lb showed mild concentric left ventricular hyper- trophy with good overall systolic function and no left ventricular outflow tract gradient. How- ever, the apical endocardium could not be ade- quately visualized. Due to the persistent dysp- nea, a cardiac catheterization was performed. It revealed a tight lesion in the proximal segment of the left anterior descending (LAD) artery (Fig. 2A). The LAD lesion was dilated, followed by deployment of a 2.75 mm × 18 mm Cypher stent, with no residual stenosis (Fig. 2B). Left ventriculography was not performed in order to avoid excessive use of radiographic contrast material. The ECG changes were then sus- pected to be due to anterolateral ischemia sec- ondary to the tight LAD lesion. One month later, the patient returned with persistence of her symptoms. Repeat ECG showed persistence of the T-wave inversions in the precordial leads. Transthoracic echocardiography was repeated to assess the anterior and apical wall motion. Due to the poor visualization of the anterior wall and apex, an intravenous bolus of 1.0 mL of Optison contrast agent (Amersham plc.) was ad- ministered over 1 second, followed by a flush of 0.9% sodium chloride, to enhance image quality. Contrast-enchanced images revealed a spade- like deformity of the left ventricle consistent with apical hypertrophic cardiomyopathy (Fig. 3). The apical thickness was obtained from the apical four-chamber view at end-diastole as the maximal distance from the apical endocardium to the visceral pericardial layer. It measured 1.8 cm. The posterior wall thickness was obtained Vol. 22, No. 10, 2005 ECHOCARDIOGRAPHY: A Jrnl. of CV Ultrasound & Allied Tech. 831