Background: Hypertrophic cardiomyopathy is defined by the presence of increased left ventricular (LV) wall thickness that is not solely explained by abnormal loading conditions. Its apical form is associated with higher risk for deterioration of heart failure and sudden cardiac death. 

Aim / Purpose: Through this case report we want to present a very rare case of biventricular apical hypertrophy and to highlight the pivotal role of computed tomography but especially of contrast echocardiography in the diagnostic pathway of apical hypertrophic cardiomyopathy.

Presentation and primary Investigations:A 79-year-old woman presented to the emergency room with vertigo, dizziness and presyncope. She denied dyspnea, angina pectoris and other neurological symptoms. Her medical history consisted of arterial hypertension, which was diagnosed a long time ago. The ECG showed no signs of acute ischemia, rather changes such as negative T-wave in I and aVL and biphasic T-waves in V3-V6. It showed a sinus rhythm. The blood tests are shown in Table 1. The physical exam presented no pathological aspects. 

Imaging: A CT-Examination demonstrated no signs of cranial, spinal or pelvic fracture. Because of the elevated level of D-Dimer CT angiography of the chest was performed and revealed a minor peripheral pulmonary embolism of right artery segment I. Other than that, it was able to see a left ventricular hypertrophy with aspects of apical aneurysm. Transthoracic echocardiogram was performed for further delineation of cardiac structural abnormalities. Biventricular systolic function was preserved with no evidence of LVOT obstruction. Ultrasonic contrast enhancing agent (SonoVue®) was used for better evaluation of right ventricular apex and LV apical aneurysm. No thrombus was recognized in the apical region. Other than that, we couldn’t identify an apically displaced papillary muscle. During the contrast examination we could highlight the typical “ace of a spade”- form of the biventricular, apical hypertrophic cardiomyopathy, confirming the diagnosis of biventricular apical HCM ( BV-AHCM). The patient refused to undergo cardiac catheterization and magnetic resonance (cardiac MRI).

Treatment: Heart failure therapy was optimized according to the current German and European guidelines and the patient was recommended a screening of her children. Holter Monitor showed no sign of arrhythmia, and no specific antiarrhythmic therapy was initiated. 

Through this case report we would like to raise awareness toward the “forgotten” ventricle and to always bear in mind to look for two “aces of spades” preferably using contrast agent in hypertrophic cardiomyopathy. Its diagnosis and treatment in elderly represent a complex and challenging scenario because of atypical presentation aspects, which lead patients to frequent hospitalization, and which is more important to cardiovascular complications such as sudden cardiac death, malignant arrhythmias, stroke and progressive heart failure

Figure 1 : A – four chamber view ; B – four chamber view with contrast enhancement; C and D– Thorax-CT

Table 1: laboratory parameters at admission