case_images: PMC11833696_01
case_images: (A) Hallmark chronic endomyocardial fibrosis features. (B) Cardiac magnetic resonance pathognomonic sign: 'double V sign': a three-layered patter of normal myocardium (orange asterisk), endocardial thickening and fibrosis (green asterisk), and the presence of overlying thrombus (red asterisk) in the affected ventricular apex. (C) Endomyocardial fibrosis physiopathology. (D) Endomyocardial fibrosis clinical presentation. CMR, cardiac magnetic resonance; EMF, endomyocardial fibrosis.
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case_images: PMC11833696_01_ytaf039il2.jpg
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case_images: PMC11833696_02
case_images: Case 1 images. (A) Pulsed Doppler demonstrates a restrictive filling pattern. Tissue Doppler showed a septal e' wave at 5 cm/s. (B) Echocardiogram shows apical thickening with wedge-shaped internal calcification (arrow). In the lower row, we observe cardiac magnetic resonance in late gadolinium enhancement sequence. Two-chamber view (C) showing apical diastolic thickening and four- (D) and three-chamber views (E) showing apical endocardial enhancement with superimposed thrombus 'double V sign' (asterisk). (F) Cardiac computed tomography reformat four chambers showing apical obliteration with hypoattenuated image (85UH) and calcification.
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case_images: Transthoracic echocardiogram showed LV apical thickening with an echodense mass obliterating the apex, and the right ventricle (RV) was dilated and dysfunctional (Figure 2).
case_images: PMC11833696_03
case_images: Case 2 images. (A) Continuous Doppler at the level of the tricuspid valve with severe regurgitation (peak velocity of 3 m/s) and septal e' wave tissue Doppler 6 cm/s (not shown). (B) Echo apical four-chamber view focused on the left ventricle, and (C) transoesophageal echocardiography mid-oesophageal view at 60  shows calcified endocardium superimposed on apical left ventricular hypertrophy with a maximum thickness of 15 mm (red arrows). (D-F) Late gadolinium enhancement sequences showing the 'double V sign' (red arrows) with endocardial enhancement and superimposed apical thrombus. (G, H) Steady-state free precession sequence in three-chamber and four-chamber views, respectively, with significant bi-atrial dilatation and biventricular apical obliteration during diastole. (I, J) Cardiac computed tomography showing large endocardial apical calcification (asterisk) and apical obliteration with hypoattenuated image. Note the pulmonary congestion with air bronchograms (orange arrow).
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case_images: T-wave inversion in leads I, AVL, V3-6. Transthoracic echocardiogram showed apical thickening of 27 mm with endocardial calcification and atrial dilatation with a restrictive filling pattern (Figure 3).