Direct visualization of myocardial fibrosis in vivo remains a challenge. In hypertrophic cardiomyopathy, myocardial fibrosis is usually imaged by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR), with major prognostic implications. Extensive areas of collagen within the myocardium produce abnormal reflection of ultrasound. The ability of three-dimensional contrast-enhanced echocardiography (3DCE) to detect myocardial scars was recently emphasized in ischaemic cardiomyopathy. In the cases of three patients with hypertrophic cardiomyopathy, harmonic 3DCE was performed with an iE33 (Philips ® ) equipped with a matrix array transducer (×4 2–4 MHz). After intravenous injection of contrast (SonoVue ® , bolus of 0.5 mL), pyramidal full-volume data sets from the apical transducer position were acquired just after irruption and homogenous distribution of contrast in the left ventricle, with a high mechanical index (0.4). Compression was adjusted to soften the healthy myocardium. Gain settings were optimized. Comparison of 3DCE and LGE-CMR images clearly demonstrated agreement. For patient 1, 3DCE revealed a hyperechogen nodule in the mid septum ( Fig. 1 , panel 1a). Findings with LGE-CMR correlated with 3DCE, with the visualization of a nodular area of hyperenhancement in the mid septum ( Fig. 1 , panels 1b and 1c). In patient 2, 3DCE showed an area of hyperechogenicity for basal and mid-septal segments ( Fig. 1 , panel 2a). LGE-CMR demonstrated a large area of septal hyperenhancement ( Fig. 1 , panels 2b and 2c), well correlated with the echocardiographic findings. For patient 3, 3DCE did not show any region of hyperechogenicity ( Fig. 1 , panel 3a). In the same way, LGE-CMR did not reveal hyperenhancement ( Fig. 1 , panels 3b and 3c). Although further studies are required, these first observations may suggest the ability of 3DCE to detect myocardial fibrosis in hypertrophic cardiomyopathy.
