Apical aneurysm and left ventricular hypertrophy

Abstract

Left ventricular hypertrophy represents an adaptation of the heart to the increased afterload that occurs in systemic hypertension. However, in some cases, the presence and the degree of hypertrophy do not correlate with the severity of hypertension, which has already been described in the elderly and in patients with pheochromocitoma 1 . Other factors, such as the level of the arterial blood pressure, plasmatic renin activity and circulating catecholamines seem to relate to the degree of hypertrophy. Because hypertension is a disease with a high prevalence in the population, an association with hypertrophic cardiomyopathy in some patients is also a possibility 2 . This is the report of a patient with moderate hypertension and evidence of severe hypertrophy associated with the presence of an apical aneurysm of the left ventricle, which is a complication rarely seen in hypertrophic cardiomyopathy 3 that has not been described in cases of isolated hypertension. Case ReportThe patient is a 59-year-old woman with a history of smoking cigarettes and hypertension since 1982 when she started regular control of her blood pressure as an outpatient. She reported no family history of heart disease or sudden death. On physical examination her blood pressure was 160/95mmHg and her heart rate was 76bpm. The apical thrust was palpable in the 5 th intercostal space of the left midclavicular line and had an increased impulse. On cardiac auscultation, heart sounds were rhythmic and had normal intensity, and a ++/4+ ejective systolic murmur could be heard at the base of the precordium with no irradiation. Carotid pulse was normal on palpation. Exams to diagnose secondary causes of systemic hypertension were negative, as were serological exams for Chaga's disease.The patient was asymptomatic, with controlled levels of blood pressure on atenolol and chlortalidone until mid-1997. She then began to experience fatigue and increasing precordial pain with exercise. Eletrocardiogram and echocardiogram showed signs suggestive of left ventricular hypertrophy.In August 1998, the patient had an ictal episode of aphasia of expression and left hemiparesis that lasted for 30 minutes and showed complete regression. Her clinical presentation did not suggest hypertensive crisis and the diagnosis of probable thromboembolic transient ischemic attack was made. Examinations to detect the source of the emboli were performed. Severe hypertrophy of the left ventricle was diagnosed by echocardiography, where a 21mm septum and a 16mm posterior wall thickness were observed. An intraventricular gradient of 120mmHg was detected by Doppler.MRI (figure 1) confirmed the echocardiographic finding of severe hypertrophy associated with a mesoventricular obstruction of the left ventricle and the presence of an apical aneurysm with a thrombus. Hypertrophy of the right ventricle was also present. Coronary angiography was indicated and the coronary arteries were shown to be normal. Endomyocardial biopsy of the right ventricular was then indicated due to the unknown caus...

Left Apical Aneurysm in a Patient with Severe Aortic Valve Stenosis

“…On admission, transthoracic and transesophageal echocardiography confirmed the diagnosis of severe aortic valve stenosis (aortic valve area, 0.79 cm 2 ; maximal transvalvular gradient, 80 mm Hg; mean transvalvular gradient, 50 mm Hg) and valve incompetence of grade I. The mitral and tricuspid valves also showed slight incompetence of grade I. Echocardiographic examination revealed normal right and left ventricular contractility.…”

“…Soufen et al described an apical aneurysm with septum hypertrophy in a patient with severe systemic hypertension without history of HOCM. 2 Their patient, a 59-year-old woman, had in her history isolated hypertension and cerebral embolism. She had an apical aneurysm with a thrombus leading to long-term oral anticoagulation with warfarin.…”

“…She had an apical aneurysm with a thrombus leading to long-term oral anticoagulation with warfarin. 2 In Brazil, the presence of an apical aneurysm is always suggestive of Chagas disease. 6 Our patient was from northern Europe and had no history of visits to Central or South America.…”