Hourglass appearance on ventriculography: insights from cardiac magnetic resonance imaging

Abstract

Clinical introduction: A 75-year-old patient with hypertension and severe aortic stenosis underwent elective coronary angiography that showed mild non-obstructive disease in the mid left anterior descending artery (LAD). A left ventriculogram, however, demonstrated segmental systolic dysfunction with dilated akinetic apex (figure 1A, see online supplementary video 1). There was no history of prior myocardial infarction and the patient had not experienced any chest pain recently. A 12-lead ECG showed widespread deep symmetrical inverted T-waves with the exception of leads I, aVL and V1 (see online supplementary figure S1). Cardiac MRI (CMR) was performed to further delineate the morphology of the left ventricle (LV) and a representative frame in late gadolinium phase is shown (figure 1B).

Question: Above information is most likely consistent with: Takotsubo cardiomyopathyLeft ventricular pseudoaneurysmApical variant of hypertrophic cardiomyopathy (HCM) with aneurysm formationA sequel of prior myocardial infarction in the setting of aortic stenosisLeft ventricular non-compaction.