Similar to Left ventricular noncompaction or "spongy myocardium" overlapping with dilated LV cardiomyopathy (perhaps, it is transformation NCLV to DCM) that can be diagnosed at any age. ECHO is showed a thin compacted epicardial layer and an extensive non-compacted endocardial layer, with prominent trabeculation and deep recesses that communicate with the left ventricular cavity. Segments involved are basal and mid ventricular (especially lateral) with evidence of direct blood flow from the ventricular cavity into deep intertrabecular recesses by colour Doppler.Criteria based on an end systolic ratio of non-compacted to compacted layers above 3 (3,1\1). 

The classical triad of complications - heart failure, ventricular arrhythmias and systemic embolic events. Due to poor prognosis necessary to consider the possibility of implantation of cardiac defibrillator and evaluation for heart transplantation.

Interestingly, what is an ECG? (or HM ECG)

I do agree: LVNC is one of the diagnostic possibilities looking at the present phenotype. There is no doubt there are evident apical recesses but care should be taken to avoid basal segments near the papillary muscles. Interestingly, according to criteria reported by Jenni et al, measurements of the compacted and non compacted ratio should be made at end-systole (that is different from MRI criteria). I also agree that EKG is important and according to LV motion, a LBBB pattern is expected. 

Thank you very much Dr. Vaikhanskaya and Dr. Calvo-Iglesias  for your consideration and collaboration. I agree with your diagnosis but actually I have never seen a similar case before thats why I asked for different opinions. The ECG of the case was added and it showas a LBBB pattern. 

Looks like non-compaction. She has considerable dyssynchrony and I would vote for a CRT pacemaker. I have seen LVNC-like ventricles that "normalize" a bit after resynchronization and heart failure treatment.

Interestingly, the left atrium is small. I would have expected atrial dilatation and maybe AFIB. Has something extra pushed this patient into congestion?

In deed this supposed to be a left ventricular non-compaction cardiomyopathy. In the long axis view the left atrium seemed to be enlarged to, but I did not see any mitral regurgitation. May this is the reason why the patients has not developed AF so far. THe LBBB is often seen in LVNC and therefore the pat. will benefit from CRT pacing as Benjamin and Niels mentioned, aside from good anticongestive control.

I would like to perform cardiac MRI for this patient. We have seen in some patients with LVNC that there is a discrepancy between how low EF is and clinical symptoms (NYHA class): they are in NYHA I-II with EF 20-25% ! They used to be superresponders with CRT on top of heart failure treatment. Anticoagulation is still a problem under discussion in these patients.

Discussion is complete. Agree to CRT pacing and MRI of heart and heart failure treatment.

In my clinical practice, I have observed a case of infiltration and edema of the myocardium on the background of panmyocarditis, which led to a thickening of the myocardium (predominantly papillary muscles), that by echocardiography looked like a layer of of non-compact myocardium, which disappeared after the relief of inflammation.

Does your patient any symptoms of myocarditis?

Septal Ischemia, Significant Pulmonary Hypertension[↓sed PAT, 2° LV failure] .

Eccentric LVH[2° ? Underlying HTN]

EKG-LAE, LBBB

CRT recommended given LV Dilataion + ↓sed EF\LBBB

Is she a known hypertensive? It may be advanced hypertensive heart failure. Definitely, further investigation are needed to rule out other rare causes of the biventricular failure including storage disorders.The patient will definitely benefit from anticoagulants and devise based therapy including optimized medical therapy.