1009 INTRAMYOCARDIAL HEMORRHAGE: A DIFFERENTIAL DIAGNOSIS OF HYPERTROPHY


 Hypertrophic cardiomyopathy (HCM) is a muscle disorder with impairment of microvascular circulation. Intramyocardial hemorrhage (IMH) represents a possible complication in patients with myocardial infarction (MI) involving left ventricular (LV) myocardial tissue and micro vascularization. We describe a case of a HCM patient with anterior STEMI with evidence of IMH.
 
 
 A 61-years-old male patient from Sri Lanka with no prior medical history presented to the emergency Department with persistent chest pain started from 3 hours. He was a smoker. The first ECG revealed ST-segment elevation in V2-5 leads and symmetric negative T-wave in I and aVL leads. Primary percutaneous coronary intervention (PCI) was performed, revealing sub-obstructive stenosis in the proximal left anterior descending artery (LAD) associated with extensive endoluminal thrombus. Invasive coronary angiogram also showed a critical stenosis in distal right coronary artery (RCA) and a chronic occlusion in the proximal left circumflex coronary artery (LCx). After tirofiban intravenous administration and rheolytic thromboaspiration, drug-eluting stent (DES) implantation of the LAD artery was performed successfully.
 Transthoracic echocardiography, performed after primary PCI, documented akinesia of proximal LAD territories and LV ejection fraction (EF) of 45%. The curious feature was the evidence of concentric hypertrophy in absence of an apparent reason. Therefore, three days later, the patient underwent cardiac magnetic resonance (CMR), showing mildly reduced LV function (LVEF 42%). CMR images also showed subendocardial late enhancement in proximal LAD territory and transmural LGE with no-reflow phenomenon in mid-apical anteroseptum. (Figure) On T2-weighted images, there was an hypointense core enclosed in the transmural hyperintense area in basal-mid anteroseptum, likely in keeping with intramyocardial hemorrhage (Figure). After a staged PCI with the implant of another DES in RCA, patient was discharged in DAPT (aspirin + ticagrelor).
 
 
 
 IMH is considered a severe form of MVO, which occurs in the core of the infarcted area in patients with myocardial infarction. We describe an intriguing case with IHM in HCM patient. Moreover, it raises several questions on which is the best treatment option.
