HomeCirculation: Cardiovascular ImagingVol. 5, No. 5Letter by Puntmann et al Regarding Article, “Prevalence and Clinical Profile of Myocardial Crypts in Hypertrophic Cardiomyopathy” Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBLetter by Puntmann et al Regarding Article, “Prevalence and Clinical Profile of Myocardial Crypts in Hypertrophic Cardiomyopathy” Valentina O. Puntmann, MD, PhD, MRCP, Christian Jansen, MD, PhD and Eike Nagel, MD, PhD Valentina O. PuntmannValentina O. Puntmann Department of Cardiovascular Imaging, King’s College London, London, United Kingdom Search for more papers by this author , Christian JansenChristian Jansen Department of Cardiovascular Imaging, King’s College London, London, United Kingdom Search for more papers by this author and Eike NagelEike Nagel Department of Cardiovascular Imaging, King’s College London, London, United Kingdom Search for more papers by this author Originally published1 Sep 2012https://doi.org/10.1161/CIRCIMAGING.112.977074Circulation: Cardiovascular Imaging. 2012;5:e66To the Editor:With interest we read the recent contribution of Maron et al1 in Circulation: Cardiovascular Imaging. The authors report on the prevalence of crypts as a distinctive morphological expression of hypertrophic cardiomyopathy (HCM), which is only identifiable by means of cardiovascular magnetic resonance (CMR). In a cohort of phenotypically nonexpressed but gene-positive family members (n-31), crypts were highly prevalent (>60%) but uncommon in patients with expressed hypertrophic phenotype (n-292; 4%). Because no crypts were found in apparently healthy but genotype-naive controls (n-98), the authors concluded that crypts might serve as a novel marker to identify individual HCM family members who would benefit from further screening. Maron et al take the advantage of the excellent spatial resolution of CMR and marry it with genetic testing into a novel disease marker on an individual level. In light of complexities of genetic testing and counseling in the HCM population and their affected family members, the suggestion of Maron et al1 aims to improve the pretest likelihood of the final diagnosis.Even though this provides an exciting aspect of redefining family screening, it is important to put these novel findings into perspective. With improving accuracy of imaging techniques, led by CMR, we are increasingly confronted with findings, not or rarely observed before. As such, it is important to highlight that the occurrence of crypts is in no way restricted to patients with HCM or phenotype-negative gene carriers as also claimed previously,2 but rather a common finding in a population that undergoes CMR imaging. In a systematic review of patients undergoing CMR imaging, crypts were found in ≈5% of healthy volunteers and patients with HCM and even 22% in patients with surgically relieved congenital pulmonary valve stenosis, also showing that crypts can be found well beyond the basal inferior wall.3 In this context, it is also important to highlight that brighter areas in late gadolinium-enhanced images may be falsely diagnosed as scar of fibrosis but truly stem from the bright signal of the invaginated blood pool within the crypt. This can usually be demonstrated by an additional crosscut through the questionable area. Therefore, the authors are rightly cautious in their interpretation about the significance of crypts in genotype-positive family members because these conflicting findings require larger sample sizes to clarify the prevalence of crypts in different patient populations, as well as prospective studies to determine the relevance of crypts for the development of disease or unfavorable outcomes.Valentina O. Puntmann, MD, PhD, MRCPChristian Jansen, MD, PhDEike Nagel, MD, PhDDepartment of Cardiovascular ImagingKing’s College LondonLondon, United KingdomDisclosuresNone.