Hourglass appearance on ventriculography: insights from cardiac magnetic resonance imaging

Area of Science:

• Cardiology
• Cardiovascular Imaging
• Clinical Diagnostics

Background:

• A 75-year-old patient with hypertension and severe aortic stenosis presented with findings suggestive of cardiac dysfunction.
• Coronary angiography revealed mild non-obstructive left anterior descending artery disease.
• Left ventriculography showed segmental systolic dysfunction with a dilated, akinetic apex, atypical for the patient's history.

Purpose of the Study:

• To evaluate the diagnostic consistency of clinical findings in a patient with severe aortic stenosis.
• To differentiate between various potential cardiac conditions including Takotsubo cardiomyopathy, left ventricular pseudoaneurysm, hypertrophic cardiomyopathy, myocardial infarction sequelae, and left ventricular non-compaction.

Main Methods:

• Electrocardiogram (ECG) analysis showing widespread deep symmetrical inverted T-waves.
• Cardiac MRI (CMR) to assess left ventricular morphology and function.
• Review of patient history including hypertension, aortic stenosis, and absence of prior myocardial infarction or recent chest pain.

Main Results:

• ECG findings were atypical for myocardial infarction.
• Left ventriculogram demonstrated an akinetic apex, inconsistent with prior infarction.
• Cardiac MRI provided further morphological detail of the left ventricle.

Conclusions:

• The clinical presentation, ECG abnormalities, and ventriculogram findings are highly suggestive of Takotsubo cardiomyopathy.
• Other differential diagnoses such as left ventricular pseudoaneurysm or apical hypertrophic cardiomyopathy were considered but deemed less likely.
• Further investigation with CMR confirmed the characteristic features of stress-induced cardiomyopathy.