case_images: PMC11802179_01
case_images: Phonocardiography and electrocardiography. Phonocardiography at the apex shows a high-pitched murmur during early to mid-systole (A, arrow). Note the absence of the fourth sound. Electrocardiography shows no left ventricular hypertrophy (i.e., R-wave amplitude in V5, 1.39 mV) (B).. ECG: electrocardiography; S1: the first sound; S2: the second sound
case_images: cureus-0017-00000077097-i01.jpg
case_images: PMC11802179_01_cureus-0017-00000077097-i01.jpg
case_images: FIG1
case_images: On examination, a grade 2 systolic ejection murmur was heard without additional heart sounds including the fourth sound (Figure 1A). Electrocardiography showed slight ST-T changes in leads I, aVL, and V6 without left ventricular hypertrophy (Figure 1B).
case_images: Echocardiography. Apical four- and two-chamber views at end-diastole (A and B) and end-systole (C and D) show mid-ventricular obstruction (C, arrow) with a suspicion of an apical chamber (D, asterisk). Doppler imaging shows a peak velocity of approximately 3.1 m/s in the mid-ventricle (E). Note an early diastolic flow from the apex to the base of the left ventricle during a period of isovolumic relaxation to diastole or paradoxic jet flow (F, arrow). Two-dimensional speckle-tracking echocardiography reveals a global longitudinal strain (GS) of -11.3% with an apical sparing pattern (G).. LA: left atrium; LV: left ventricle; RV: right ventricle; HR: heart rate; SEPT: septal; INF: inferior; POST: posterior; LAT: lateral; ANT: anterior; ANT SEPT: anterior-septal
case_images: cureus-0017-00000077097-i02.jpg
case_images: PMC11802179_01_cureus-0017-00000077097-i02.jpg
case_images: FIG2
case_images: Echocardiography demonstrated a left ventricular ejection fraction of 69% with diffuse hypertrophy in both the left and right ventricles, 17 to 19 mm and 7 to 8 mm, respectively (Figures 2A, 2B). Notably, MVO was suspected with a peak velocity of 3.1 m/s (Figures 2C-2E), findings indicative of the presence of an apical chamber, which was confirmed by the presence of PJF (Figure 2F) . Two-dimensional speckle-tracking echocardiography demonstrated a global longitudinal strain of -11.3% with an apical sparing pattern (Figure 2G).
case_images: Scintigraphic and pathological findings. Technetium-99m hydroxymethylene diphosphonate scintigraphy shows diffuse uptake in the left ventricle more than in the bone (A). Endomyocardial biopsy of the right ventricle shows positive deposits on Congo red staining (B; original magnification, x200) and apple green appearance on polarizing microscopy (C; original magnification, x200).
case_images: cureus-0017-00000077097-i03.jpg
case_images: PMC11802179_01_cureus-0017-00000077097-i03.jpg
case_images: FIG3
case_images: Technetium-99m hydroxymethylene diphosphonate scintigraphy showed diffuse uptake in the left ventricle that was greater than that in the bone (Figure 3A), findings consistent with ATTR cardiac amyloidosis .