# Beyond Hypertrophy: A Case of Mid-ventricular Obstructive Hypertrophic Cardiomyopathy With Apical Sequestration

## TL;DR

This case study describes a rare heart condition where mid-ventricular obstruction leads to an isolated apical chamber, causing complications like blood clots and ischemic injury.

## Contribution

The paper highlights apical sequestration as a high-risk variant of MVO-HCM and emphasizes the role of cardiac MRI in diagnosis.

## Key findings

- Mid-ventricular hypertrophy caused an isolated apical chamber with impaired perfusion.
- Cardiac MRI revealed intramural fibrosis, a small apical thrombus, and ischemic injury.
- Coronary angiography showed no obstructive disease, indicating obstruction-related flow limitation.

## Abstract

Apical sequestration is an often overlooked manifestation of mid-ventricular obstructive hypertrophic cardiomyopathy (MVO-HCM), in which dynamic mid-ventricular obstruction creates an anatomically and functionally isolated apical chamber with impaired distal perfusion. We describe a patient with MVO-HCM who developed apical sequestration complicated by flow stagnation, ischemic injury, and a small mural apical thrombus. Transthoracic echocardiography showed marked mid-ventricular hypertrophy with systolic narrowing. At the same time, cardiac magnetic resonance provided a more comprehensive characterization by demonstrating a mechanically trapped apical chamber, mid-ventricular intramural fibrosis, a small apical thrombus, and transmural late gadolinium enhancement consistent with ischemic injury. Coronary angiography revealed no obstructive disease, supporting a mechanism of obstruction-related flow limitation rather than epicardial coronary pathology. This case underscores apical sequestration as a high-risk morphological and physiological variant of MVO-HCM. It highlights the value of multimodality imaging, particularly cardiac magnetic resonance, in identifying this uncommon presentation and guiding clinical management.