Echocardiography 2016; xx: 1–2 wileyonlinelibrary.com/echo 1 IMAGE SECTION Multple myocardial crypts: multmodality imaging evaluaton João Gonçalves Almeida M.D. | Ricardo Ladeiras-Lopes M.D. | Nuno Betencourt Ph.D. | Nuno Ferreira M.D. | José Ribeiro M.D. | Vasco Gama Ribeiro M.D. A 56-year-old woman was referred to our cardiology consult due to atypical chest pain. She had arterial hypertension and dyslipidemia, without family history of premature coronary disease, cardiomyopa- thy, or sudden cardiac death. Electrocardiogram showed T-wave in- version in V 1 –V 3 and transthoracic echocardiography (TTE), despite a mild elevaton of lef ventricular mass index (posterior wall thick- ness: 12 mm; septal wall thickness: 13 mm; mass index: 120 g/m 2 ), was unremarkable. Coronary computed tomography angiography (CCTA) showed no coronary epicardial disease, but revealed multple myocardial crypts, predominantly in the septum (Fig. 1, Panels A1–3). Cardiac magnetc resonance imaging (MRI) demonstrated mild lef ventricle hypertrophy of septal predominance (maximum 13 mm) and multple myocardial crypts in the septum, the deepest with 13 mm, in the basal segment of anterior septum (Fig. 1, Panels B1–3; see Video S1). There was no late enhancement or abnormalites in the adenos- ine stress perfusion study. One year afer the diagnosis, we repeated TTE, this tme with intravenous contrast (Sonovue (Bracco, Milan, Italy)), which unveiled the same fndings of CCTA and MRI (Fig. 1, Panels C1–3; see Video S2 and Video S3). Diagnostc work-up in- cluded genetc testng for hypertrophic, dilated, and noncompacton cardiomyopathies, which was negatve. In follow-up, the patent re- mains asymptomatc under medicaton with beta-blockers, without any cardiovascular events. Myocardial crypts have been arbitrarily described as V-shaped fssures, extending >50% into compact myo- cardium. 1 Their prevalence seemed to be higher in hypertrophic cardiomyopathy patents, partcularly in phenotypically normal pa- tents with positve genetc test or familial history. 2 However, single or paired myocardial crypts were also found in apparently normal patents, predominantly in inferobasal segments. 1,3 Therefore, de- spite being more prevalent in hypertensive and HCM patents, they appear to be relatvely common (3.6%) in the normal populaton. 4 Myocardial crypts, partcularly if multple, may represent a prephe- notypic marker of HCM, but in otherwise normal patents with single or paired crypts, they probably represent a normal variant and an incidental fnding. 4 Clinical signifcance of myocardial crypts remains poorly understood, and prospectve studies are needed to determine their true prevalence and prognosis. CONFLICT OF INTEREST The authors have no funding, fnancial relatonships, or confict of interests to disclose. REFERENCES 1. Johansson B, Maceira AM, Babu-Narayan SV, et al. Clefs can be seen in the basal inferior wall of the lef ventricle and the interventricu- lar septum in healthy volunteers as well as patents by cardiovascular magnetc resonance. J Am Coll Cardiol. 2007;50:1294–1295. 2. Maron MS, Rowin EJ, Lin D, et al. Prevalence and clinical profle of myocardial crypts in hypertrophic cardiomyopathy. Circ Cardiovasc Imaging. 2012;5:441–447. 3. Petryka J, Baksi AJ, Prasad SK, et al. Prevalence of inferobasal myocar- dial crypts among patents referred for cardiovascular magnetc reso- nance. Circ Cardiovasc Imaging. 2014;7:259–264. 4. Child N, Muhr T, Sammut E, et al. Prevalence of myocardial crypts in a large retrospectve cohort study by cardiovascular magnetc reso- nance. J Cardiovasc Magn Reson. 2014;16:66. © 2016, Wiley Periodicals, Inc. We describe a rare case of multple myocardial crypts with atypical septal localiza- ton, evaluated with multmodality imaging. Although myocardial crypts seem to be more prevalent in hypertensive and hypertrophic cardiomyopathy patents, they are also occasionally found in apparently normal patents. Their clinical signifcance remains poorly understood. KEYWORDS contrast echocardiography, multmodality imaging, myocardial crypts Cardiology Department, Vila Nova de Gaia/ Espinho Hospital Center, Vila Nova de Gaia, Portugal Correspondence João Gonçalves Almeida, M.D., Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal. Email: joaotgalmeida@gmail.com DOI: 10.1111/echo.13280