| Objective The morphologic characteristics,functional characteristics and clinical manifestations of left ventricular apical aneurysms in patients with hypertrophic cardiomyopathy were observed by contrast echocardiography(CE),to study the value of contrast echocardiography in the diagnosis of left ventricular apical aneurysms in hypertrophic cardiomyopathy,the clinical characteristics of HCM patients with left ventricular apical aneurysms and the influencing factors for the formation of left ventricular apical aneurysms.Methods Of 465 patients with HCM who were continuously diagnosed,101 patients who were suspected or diagnosed with left ventricular apical aneurysms by echocardiography or cardiac magnetic examination(CMR)and 18 patients(n=119)who did not have left ventricular apical aneurysms but agreed to undergo CE were included in this study.General clinical data,blood biochemical indicators,electrocardiogram data and skull plain CT indicators were collected,and echocardiography and CE were performed simultaneously.The latter two were focused on the wall thickness,the shape of the left ventricle and apex,the pressure difference in the left ventricle and the direction of blood flow,the motion function of the apical ventricle wall,the perfusion status of the apical ventricle wall and the thrombus in the left ventricle.Traditional echocardiography combined with the measurement of the change rate of the aneurysms area during the systolic and diastolic period was used to evaluate the motion of the aneurysm wall.The pressure difference and the early diastolic paradoxical jet flow(apex flows toward base)and the elastic recoil(base flows to apex)flow in the early astolic period were mainly observed for the intracavity blood flow.Subsequently,according to the results of echocardiography and CE,119 patients were divided into ventricular aneurysms group(absent or abnormal wall motion),near left venricular apical ventrical aneurysm(near LVAA)group(normal wall motion)and nonventricular aneurysms group,and the differences of left ventricular morphology,function and clinical characteristics among each group were compared.Results1.Incidence,morphologic and functional characteristics of left ventricular apical aneurysmsAmong 465 patients with HCM,25(5.4%)were diagnosed with left ventricular apical aneurysms(LVAA)by CE.Among them,wide-neck type(n=7,28%),hourglass type(n=4,16%)and water drop type(n=14,56%);There were 0 cases(0%)of large aneurysms with a diameter greater than 4cm,12 patients(48%)of 2-4cm aneurysms,and 13 patients(52%)of small aneurysms with a diameter less than 2cm.Hypertrophy involved the middle left ventricle in 4 patients(16%)and the apex in 21 patients(84%).Middle left ventricular obstruction in 11 patients(44%);Obstruction in the middle and lower left ventricle in 2 patients(8%);Left ventricular outflow tract obstruction in 1 patient(4%);There were early diastolic paradoxical jet flow in the neck of aneurysms in 15 patients(60%)and elastic recoil flow in 1 patient(4%).Transmural perfusion decreased in 25 patients(100%).No thrombus was found in any of ventricular aneurysms.2.Incidence and morphologic and functional characteristics of near-left venricular apical aneurysm.Of 119 patients with HCM,the CE of 25patients(21%)showed a small fissure or oval cystic cavity with normal motor function at the distal apex of the heart at the end of the systolic period,which was defined as near LVAA.Among them,fissure(n=23,92%),elliptic sac(n=2,8%);Hypertrophy involved the middle left ventricle in 8 patients(32%)and the apex of the heart in 17 patients(68%).Middle left ventricular obstruction in 8 patients(32%);Obstruction in the middle and lower left ventricle in 3 patients(12%); Left ventricular outflow tract obstruction in 2 patients(8%);Paradoxical jet flow appeared in 1 patient(4%)and elastic recoil flow in 12 patients(48%).Subintimal perfusion decreased in 25 patients(100%)and transmural perfusion decreased in 0 patient(0%).No thrombus formation was observed in all near LVAA.3.Comparison of special indicators related to ventricular aneurysm among three groups.Patients without ventricular aneurysms were more likely to appear in HCM confined to base of ventricular septum and pure type Ap HCM confined to the apex,while patients with ventricular aneurysm and near left venricular apical aneurysm HCM were more likely to have mixed type Ap HCM.Middle left ventricular obstruction is more common in HCM with LVAA.Middle and lower end-systolic occlusion was more common in HCM patients with near LVAA and without LVAA,and end-systolic occlusion was mainly found in the apex of the heart in patients without LVAA.Paradoxical jet flow mainly appeared in HCM patients with LVAA,while elastic recoil flow mainly appeared in near-left venricular apical ventrical aneurysm.A few patients without LVAA also showed abnormal intraventricular blood flow,but all of them were rebound blood flow.Decreased ventricular wall transmural perfusion in the apical area was only observed in LVAA,and decreased subendocardial perfusion was only observed in HCM patients with near LVAA or without LVAA.4.Comparison of general echocardiographic indexes among the three groups.The IVS and the maximum wall thickness in the ventricular aneurysms group and near-left venricular apical ventrical aneurysm group were higher than those in the nonventricular aneurysms group(all P<0.05).The EF and the mean E/E’ in the ventricular aneurysm group were higher than those in the ventricular aneurysm group(all P<0.05).SV values in both the ventricular aneurysms group and the near left venricular apical aneurysm group were lower than those non-left venricular apical aneurysm group ventrical aneurysm group(all P<0.05).There were no differences in other echocardiographic indexes among the three groups(all P>0.05).5.Comparison of general clinical data,various biochemical indexes and electrocardiogram indexesThere were no differences in the general clinical data and biochemical indexes of patients in the ventricular aneurysms group,the group with near left venricular apical ventrical aneurysm group and the group without ventricular aneurysms(all P>0.05).The proportion of patients with any lead ST segment decline and the proportion of patients with V3-V5 lead ST segment decline in the anterior wall in near LVAA group were higher than in the venricular aneurysm group and non-venricular aneurysm group(all P<0.05).There was no significant difference in the proportion of ECG ST-segment elevation patients in the venricular aneurysm group compared with the near LVAA group and the non-ventricular aneurysm group(all P>0.05).There were no differences in other ECG and arrhythmia indexes among all groups(all P>0.05).Conclusion1.Left ventricular apical aneurysm is a special subtype of HCM that represents poor prognosis,and is easy to be missed by ordinary transthoracic echocardiography.In this study,the incidence of left ventricular apical aneurysms was 5.4%,slightly higher than previous domestic and foreign studies.2.Left ventricular apical aneurysm of HCM can be divided into wide-neck type,hourglass type and water drop type by CE.Left ventricular apical aneurysm is mainly small and medium aneurysm with diameter less than 4cm.3.The degree of ventricular wall hypertrophy,whether the hypertrophy involves the middle part of the left ventricle,and whether there is obstruction or even occlusion in the left ventricle are contributing factors to the formation of left ventricular apical aneurysm.4.The early diastolic paradoxical jet flow and elastic recoil flow in the early stage of left ventricular diastole are strong indicators of the formation of left ventricular apical aneurysms.5.It is a convenient and reliable method to measure the area change rate of left ventricular apical aneurysm by CE combined with visual cap movement by echocardiography.6.Based on the results of CE,this study proposes the concept of near-left venricular apical aneurysm which is the special subtype of hypertrophic cardiomyopathy. |
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