OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY: A CASE REPORT

Birry Karim1, Ika Prasetya Wijaya1

1. Cardiovascular Division, Internal Medicine Department, Faculty of Medicine
University of Indonesia / Cipto Mangunkusumo National Hospital

Introduction: Hypertrophic cardiomyopathy (HCM) is the most common genetic disease

of the heart. Its prevalence is estimated in 1 per 500 individuals. The disorder has a variable
presentation and carries a high incidence of sudden death in young athletes.
Case Illustration: A 28-year-old male patient was referred to our outpatient clinic with a
previous diagnosis of coronary arterial disease suspicion. He reported no significant
symptom or history. Repeated electrocardiographs had been performed and showed T wave
inversion in lead I, aVL, V2-V6. At our clinic, we found no abnormality from the physical
examination. An echocardiography was performed and demonstrated asymmetric
hypertrophy of the interventricular septum, with systolic anterior motion of the mitral valve
and severe diastolic dysfunction, indicating a significant left ventricular outflow tract
obstruction. A cor angiography showed only myocardial bridging of the left anterior
descending artery and there was no stenosis detected.
Discussion: HCM is inherited in an autosomal dominant manner. Many patients with
hypertrophic cardiomyopathy are asymptomatic or mildly symptomatic. Our patient has no
abnormal sign and symptom and no history of sudden cardiac death in the family. Common
ECG findings include ST-T wave abnormalities, left atrial enlargement, and LV
hypertrophy. Obstructive hypertrophic cardiomyopathy is due to mid systolic obstruction
of flow through the LV outflow tract. The hallmarks of the obstructive HCM consist of
systolic anterior motion of the anterior mitral valve leaflet, septal wall thickness of > 15
mm, and asymmetrical septal hypertrophy with a ratio of septal wall thickness to posterior
wall thickness of greater than 1.4 : 1. Continuous wave Doppler reveals an elevated flow
velocity across the LV outflow tract. A cardiac catheterization is useful to determine the
degree of outflow obstruction, cardiac hemodynamics, the diastolic characteristics of the
LV and LV anatomy, and coronary anatomy. Transcatheter septal alcohol ablation is
performed to relieve the LV outflow obstruction by intentional infarction of a portion of
the interventricular septum.
Conclusion: HCM may have variable presentation and may be asymptomatic. The
obstruction of LV outflow tract is a prevalent characteristic which may influence clinical
outcome patterns and mortality rates. Although it detectable in the routine evaluation, it
requires detailed, static and dynamic investigation by imaging methods in order to improve
the diagnosis and the management.
Key words: Obstructive hypertrophic cardiomyopathy