A 35-year-old woman was referred to our centre for clinical management of hypertrophic cardiomyopathy (HCM) with left ventricular (LV) systolic dysfunction (end-stage evolution). She was recently diagnosed elsewhere because of palpitations. Her 7-year-old daughter underwent familiar screening and she was diagnosed with classic HCM. She was completely asymptomatic without extracardiac or systemic manifestations. During the following years, they both experienced a similar clinical course with worsening dyspnoea and progressive deterioration of LV systolic function. They both underwent heart transplantation, the mother at the age of 47 and the daughter at the age of 23, respectively. Many diagnostic hypotheses, including sarcomeric HCM, Anderson-Fabry disease, glycogen storage diseases and mitochondrial cardiomyopathies have been taken into account. The diagnostic work-up included serial electrocardiogram and echocardiographic assessments, pathologic evaluation of the explanted hearts and genetic analysis of 8 sarcomeric and 3 metabolic genes. Even if a shared HCM phenotype (LV systolic dysfunction in two first-degree female family members associated with a likely autosomal dominant inheritance and absence of extracardiac or multisystemic manifestations) could support a temptative diagnosis of sarcomeric HCM, a definitive diagnosis could not be reached, due to the lack of genetic analysis to confirm such diagnosis.
Case ReportA 35-year-old woman was referred to our centre for clinical management of hypertrophic cardiomyopathy (HCM) with left ventricular (LV) systolic dysfunction (end-stage phase). This condition was recently diagnosed in a different hospital because of palpitations.The electrocardiogram (ECG) showed sinus rhythm and negative T waves in the lateral leads ( Figure 1A). Echocardiography showed LV hypertrophy (maximal wall thickness 14 mm) associated with LV enlargement (enddiastolic diameter 56 mm) and LV ejection fraction (EF) of 30%. Of note, a relative wall thinning localized at the basal segment of the interventricular septum with marked akinesia was present ( Figure 1B and 1C, arrows). At that time she was mildly symptomatic, showing dyspnoea on mild efforts (NYHA functional class II). No other clinical manifestations were present and laboratory parameters were unremarkable. Medical therapy with beta-blockers and ACE-inhibitors was started.The patient's 7-year-old daughter underwent familiar screening with ECG and echocardiography. She was completely asymptomatic. No mental retardation or other extracardiac manifestations were detected and laboratory parameters were normal. The ECG showed extreme LV hypertrophy with infero-lateral pseudonecrosis and negative T waves in the infero-lateral leads (Figure 2A). Two-dimensional echocardiography disclosed a classical form of HCM with a maximal wall thickness of 16 mm at the postero-lateral wall level, a LV end-diastolic diameter of 35 mm and a LV ejection fraction of 78%. As the mother, a relative and localized wall thinning associated with hypo...