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Calcified aneurysm of left ventricular apex in apical cardiomyopathy.

A 65-year-old obese, nondiabetic, normotensive woman presented with exertional angina of 4 years' duration. She had experienced a transient ischemic attack 15 days previously. Physical examination yielded nothing unusual. An electrocardiogram showed poor precordial R-wave progression with Q waves in leads V1 through V6, II, III, and aVF, and T inversions in the precordial leads (Fig. 1). However, the patient reported no history that suggested acute coronary syndrome. 
 
 
 
Fig. 1 Twelve-lead electrocardiogram shows widespread Q waves, T inversions, and attenuated R waves. 
 
 
 
An echocardiogram showed normal left ventricular (LV) function, dimensions, and wall thickness; however, the window to evaluate the LV apex was poor. Coronary angiography showed normal coronary arteries (Fig. 2A). Injection of contrast medium into the LV revealed hypercontractile mid-LV myocardium and a spherical, calcified cavity that projected outward and communicated with the LV apex (Fig. 2B). 
 
 
 
Fig. 2 A) Coronary angiogram shows normal epicardial coronary arteries with a calcified spherical lesion at the left ventricular apex (arrow). B) Angiogram shows obliteration of the mid-left ventricular cavity (arrowhead) during systole and distortion ... 
 
 
 
Cardiac magnetic resonance (CMR) revealed asymmetric hypertrophy of the LV (interventricular septum, 14 mm; posterior wall, 10 mm). The LV myocardium contracted vigorously except at the apex, which was aneurysmal and calcified (Fig. 3). The apical aneurysm shared myocardium with the surrounding LV. Delayed-enhancement images showed transmural enhancement of the lesion, consistent with fibrosis, and confirmed the presence of mural thrombus (Fig. 4). The final diagnosis of apical hypertrophic cardiomyopathy with apical aneurysm was made on the basis of the CMR findings. 
 
 
 
Fig. 3 Single-shot cardiac magnetic resonance images (steady-state free precession) show A) septal hypertrophy and the apical aneurysm (arrow), which shares myocardium with the left ventricle (4-chamber view in diastole); and B) the apical aneurysm (arrow) ... 
 
 
 
 
 
Fig. 4 Delayed-enhancement cardiac magnetic resonance shows enhanced margins of the lesion in A) vertical long-axis and B) 4-chamber views, suggesting fibrosis and hypointense intracavitary thrombus (arrow).