BRIEF COMWNICATIONS Detection of apical hypertrophic cardiomyopathy by magnetic resonance imaging Gian Carlo Casolo, MD, Francesco Trotta, MD, Carlo Rostagno, MD, Loredana Poggesi, MD, Giorgio Galanti, MD, Giulio Masotti, MD, Carlo Bartolozzi, MD, and Roberto Piero Dabizzi, MD. Florence, Italy Apical hypertrophic cardiomyopathy (AHC) is a variant form of nonobstructive hypertrophic cardiomyopathy. It wasinitially describedin Japan and other Asian countries where it wasassociated with giant negative T wavesin the precordial ECG leads and an “ace of spades” configura- tion at end diastole on left ventricular angiograms.1*2 In western countries AHC appears to occur less frequently and some of the classic features may be incomplete or absent.3-6 Magnetic resonance imaging (MRI) is a recently developed diagnostic technique for studying the heart. Because it offers high-contrast, high-resolution tomo- graphic images, MRI is a reliable tool for obtaining anatomic information on the cardiovascular system.6*7 In this report we describe four cases of AHC initially diag- nosed by meansof noninvasive and invasive procedures, which were subsequently studied by MRI. Four patients (two men and two women) were referred to our clinic for suspected coronary artery disease. Clinical and ECG data from these four patients are shownin Table I. All of them had atypical chest pain. As a common feature their ECGs showed negative T wavesin leads I, II, and aVL and in the precordial leads (V, to V,). Results of, repeat 24-hour ECG monitoring did not show any signifi- cant ST segment and T wave variations. Results of thallium-201 scanning did not showany areas of increased uptake, and no myocardial perfusion defects were seen after exercisestress testing. Two-dimensional echocardio- graphy (2DE) was performed by means of a GE 3600 system (General Electric 3600) equipped with a 3.5 MHz electronic probe. Several imaging planes were used, including a wide-angle long axis. In two patients (Nos. 2 and 3) results of 2DE showed marked hypertrophy of the interventricular septum below the level of the chordae tendineae and toward the apex of the left ventricle (Fig. 1). In patients 1 and 4 the examination results were not definitive in assessing the distal apex. Left ventricular angiography was performed in all four patients, and images were obtained in the right anterior oblique projec- tion. All four patients had an abnormal apical obliteration From the Clinica Medica I and the Department of Clinical Physiopathol- ogy, University of Florence. Reprint requests: Gian Carlo Camlo, MD, Clinica Medica I. University of Florence, Viale Morgagni 85, 50123 Florence, Italy. Fig. 1. 2DE scanfrom patient No. 2 (four-chamber view, diastolic frame). Note abnormal hypertrophy in apical portion of left ventricle. Fig. 2. Left ventricular angiogram from patient No. 3 (right anterior oblique view). Note shape of cavity in diastole resembling“ace of spades”configuration. of the left ventricle in diastole. None of the angiograms wasjudged to show the “spade-like” deformity, although the left ventricles of patients 2, 3, and 4 closely resembled this configuration (Fig. 2). None of these patients had the 468