**6.5 Left ventricular apical aneurysm**

 These are outpouchings that appear at the left ventricular apex and can occur in those with HCM. The aneurysms are usually thin-walled and either dyskinetic or akinetic on echocardiographic images. It has been reported to occur in 15–30% of patients with the apical and midventricular variants of HCM [ 16 ], however detection of these aneurysms is not always straightforward. In the study by Yang and colleagues, the authors analyzed 1332 patients with apical HCM with cardiac magnetic resonance imaging (cMRI), and 31 patients had an apical aneurysm (2.3%). The rate of missed diagnosis of apical aneurysms by echocardiogram was 64.5% [ 17 ].

 Several adverse events have been reported with apical aneurysms such as ventricular arrhythmias, heart failure and up to sudden cardiac death. These apical aneurysms are not amenable to medical treatment and in many cases, surgical resection is recommended at the time of septal myectomy [ 18 ]. In those with midventricular obstruction, access to the left ventricular cavity can be facilitated through the aneurysm with less risk of injury to the mitral valve apparatus. Small aneurysms can be plicated, while larger ones should be resected.
