## 4 Discussion
The pathophysiological mechanisms that lead to the formation of these aneurysms are different, but the most relevant appear to be attributable to (i) systolic obstruction of the outflow tract of the left ventricle, with an increase in apical chamber pressure and a reduction in coronary perfusion pressure; (ii) the association between increased oxygen demand due to increased wall thickness and decreased oxygen supply due to reduced myocardial capillary density; and (iii) alterations of the microcirculation with a reduction in coronary reserve. These conditions, which can occur separately or simultaneously, are responsible for the onset of cardiac ischemic phenomena or true heart attacks, with the subsequent possible formation of silent aneurysms [66]. Apical aneurysms are increasinglyrecognized as an unfavorable prognostic indicator, as they appear to be associated with the onset of complications, including apical thrombus formation and thromboembolic stroke and arrhythmic events [67]. Together with asymmetric or symmetric left ventricle hypertrophy some cases reveal the involvement of the right ventricle with a variable degree of hypertrophy and cavity dimension decrease [18; 19; 23]; epidemiological data reported this association in 17.6% of the cases [68]. Typically, whitish or gray scars can be found in the hypertrophic myocardium and are often more pronounced in the septum [18; 23], and they are related to fibrotic replacement. Interestingly, the fibrosis occurs in regions which are different from those of the major epicardial coronary competence territory; thus, their regional location could be a factor suggesting the presence of HCM. The phenotypic spectrum of HCM can be further characterized by ventricular dilatation which is similar to dilated cardiomyopathy (DCM-like) [28; 29; 30]. It is considered to be the result of disease progression due to a marked fibrotic replacement of myocardial tissue, and the dilatation can affect the left ventricle or both ventricles with broad areas of fibrosis [69; 70]. The dilatation can coexist with left ventricle hypertrophic sites [20; 30]. The dilated phase of HCM is also known as the \"burned-out\" phase, and it occurs in approximately 10% of cases [70]. Microscopically, the HCM predominant features are the hypertrophy of myocyte, the myofiber disarray, and the fibrosis. The myocyte hypertrophy is common and a transverse diameter >40 \(\upmu\)m (normal range 10-15 \(\upmu\)m) has been reported [55]. The fibers also show the disarray pattern due to the architectural disorganization, in which the hypertrophic fibers are messily oriented perpendicularly or obliquely around a central core of collagen [18; 21; 25; 68]. Moreover, hypertrophic myocytes have abnormal shapes with abnormal branch or triradiate and stellate forms [19; 21]; the nuclei are bizarre and result in enlarged, hyperchromatic, or atypical shapes [19; 21; 23; 24; 25]. Even if disarray is not a pathognomonic sign of HCM, some studies describe related features that support the cardiomyopathy diagnosis. In particular, researchers reported a classification of the fiber disorganization into four classes, and they observed that the HCM cases had two predominant types [31]: small size areas of disarray in which adjacent cardiac muscle cells were aligned perpendicularly or obliquely to each other, usually forming tangled masses or \"pinwheel\" configurations (type I-A) and areas with relatively broad bundles of muscle cells (the cells were normally arranged) oriented at oblique or perpendicular angles to each other (type I-B). In this context, there are other important diagnostic considerations regarding the analysis of the amount of disarray as criteria for HCM assessment. [PERSON] et al. [31] described the technique for the quantitative evaluation of myocyte disarray. Some studies suggested that the extension of disarray should be at least 5% in the relevant part of the tissue section (i.e., ventricular septum) [31; 32], whereas other authors suggested that the disarray value should not be less than 10% [16; 71].