case_images: PMC10869175_01
case_images: The EKG indicated left ventricular hypertrophy (LVH) according to the Cornell criteria, where the combined measurement of the R wave in aVL and the S wave in V3 surpassed 20 millimeters
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case_images: PMC10869175_01_cureus-0016-00000052401-i01.jpg
case_images: FIG1
case_images: An electrocardiogram (ECG) showed normal sinus rhythm with left ventricular hypertrophy (LVH) and repolarization changes (Figure 1).  These contradictory findings triggered a more thorough echocardiogram that demonstrated elevated left ventricular outflow tract (LVOT) gradients (Figure 1), confirming HOCM.
case_images: Transthoracic echocardiogram. A transthoracic echocardiogram demonstrated severe left ventricular hypertrophy with thickened papillary muscles in the parasternal long (A, B), parasternal short (C, D), apical 4 chamber (E, F), and apical 3 chamber (G, H, I) views with preserved left ventricular ejection fraction and almost complete left ventricular cavity obliteration during systole. Impaired diastolic filling is present due to global left ventricular hypertrophy (not shown) along with abnormally turbulent flow in the left ventricular outflow tract during systole (J) due to septal hypertrophy without systolic anterior motion of the mitral valve. Continuous wave Doppler revealed resting and provoked gradients of 36 and 73 mmHg, respectively, across the left ventricular outflow tract (K) in the absence of aortic stenosis, confirming hypertrophic obstructive cardiomyopathy.. RV - right ventricle; LV - left ventricle; Ao - aorta; LA - left atrium; PW - posterior wall; PM- papillary muscle; MV - mitral valve; AV - aortic valve; LVOT - left ventricular outflow tract
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case_images: PMC10869175_01_cureus-0016-00000052401-i02.jpg
case_images: FIG2
case_images: Diastolic function was abnormal, characterized by a mildly dilated left atrium, trace tricuspid regurgitation (TR) impeding the estimation of tricuspid regurgitant velocity, an E/e' ratio of 22.30, and reduced medial and lateral e' velocities at 0.04 meters per second (Figure 2).
case_images: Positron emission tomography myocardial perfusion imaging (PET-MPI) using 13N-ammonia radiotracer exhibiting global ischemia with regadenoson-induced vasodilator stress, segment-based scoring showing a summed stress score of >10%, and increase in total perfusion deficit with stress
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case_images: FIG3
case_images: The PET-MPI revealed vasodilator stress-induced global left ventricular ischemia (Figure 3).
case_images: Coronary angiogram with an absence of obstructive coronary disease in the RCA (A), LM, LAD, LCX, (B) and their distal branches. Left ventricular end diastolic pressure of 24 mmHg was obtained. RCA - right coronary artery; PLV - posterior left ventricular; PDA - posterior descending artery; LM - left main; LAD - left anterior descending; D1 - first diagonal; LCX - left circumflex; OM1 - first obtuse marginal
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case_images: FIG4
case_images: However, her coronary angiogram revealed no obstructive coronary disease (Figure 4).
case_images: Cardiac magnetic resonance imaging. Cardiac magnetic resonance steady-state precession imaging with diastolic parasternal long (A) and short axis (B) views showing severe, concentric, left ventricular hypertrophy with left ventricular ejection fraction of 63%, late gadolinium enhancement (C), and high extracellular volume of 31%, based on pre and post-contrast T1 values (D, E) and a hematocrit of 32%, altogether suggestive of myocardial fibrosis and high-risk hypertrophic cardiomyopathy.. (IVS: interventricular septum, LA: left atrium, LV: left ventricle, LW: lateral wall, RA: right atrium, RV: right ventricle, APM: anterior papillary muscle, PPM: posterior papillary muscle)
case_images: cureus-0016-00000052401-i05.jpg
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case_images: FIG5
case_images: Cardiac MRI showed diffuse myocardial fibrosis (scar size >13%), indicating high-risk HOCM (Figure 5).