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A 60 year old man was referred to our clinic for further cardiac examination of negative T waves on the left side precordial ECG leads. Echocardiography demonstrated thickening of the left ventricular wall, particularly in the mid to apical region, which was compatible with apical hypertrophic cardiomyopathy (panel A). Five years later when R waves on the ECG declined slightly, the pattern of hypertrophy had changed to a type of mid ventricular obstruction (panel B). At that time, the intraventricular pressure gradient measured by catheterisation was 57 mm Hg. The patient was treated with a β blocker and disopyramide. However, the intraventricular pressure gradient did not completely disappear. The R waves gradually decreased with slight ST segment elevation during the ensuing 12 years. Under these conditions, the apical portion of the left ventricle became aneurysmal and there was a very large thrombus within this aneurysm (panel C). Fortunately, additional treatment with coumadin resulted in complete resolution of the thrombus without any systemic embolisation (panel D).
In this patient with hypertrophic cardiomyopathy, a sustained intraventricular pressure gradient, despite medical treatment, was related to the appearance of an apical aneurysm associated with thrombus formation.