Cardiomyopathy Echocardiography

OVERVIEW

Main types

• dilated cardiomyopathy
• restrictive cardiomyopathy
• hypertrophic cardiomyopathy
• Takotsubo cardiomyopathy

Also considered here is dynamic LVOTO without segmental hypertrophy

DILATED CARDIOMYOPATHY

• dilated chambers
• thinning of LV wall
• reduced global contractility (EF and fractional shortening)
• increased LV end-diastolic and LV end-systolic volumes
• significant MR from annular dilation
• pulmonary hypertension with TR
• spontaneous echo contrast
• thrombi
• diastolic dysfunction

RESTRICTIVE CARDIOMYOPATHY

• normal or mildly increased chamber sizes
• impaired ventricular contractility (EF and fractional shortening)
• impaired diastolic function with a restrictive filling pattern (abnormal motion of anterior mitral valve leaflet in M-mode)
• may see evidence of infiltration (amyloid)

HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY

• asymmetric septal hypertrophy
• septum involved more than the free wall (ratio of >1.5:1)
• variable right ventricular hypertrophy (>0.5cm wall thickness)
• diastolic dysfunction
• systolic anterior movement (SAM) of mitral valve apparatus
• dynamic outflow tract obstruction with an increased peak gradient below the aortic valve with continuous wave Doppler (>50mmHg)
• mid-systolic mitral valve closure

TAKOTSUBO CARDIOMYOPATHY

Definition

• acute, reversible and transient left ventricular (LV) systolic dysfunction that resembles acute coronary syndrome but does not show significant stenosis on coronary angiography
• aka stress cardiomyopathy or apical ballooning syndrome

Features on Echo

• transient hypokinesis, akinesis, or dyskinesis in LV mid-segments with or without apical involvement (days-to-weeks)
• abnormalities in regional wall motion extending beyond a single epicardial vascular distribution
• An inverted takotsubo pattern (mid-ventricular ballooning with sparing of the basal and apical segments) is a variant form
• dynamic LVOTO due to SAM
• mitral regurgitation (with or without SAM)

Complications predicting worse prognosis

• dynamic LVOTO
• MR (>grade 2)
• Cardiogenic shock
• RV dysfunction is common
• intra-cardiac thrombus (especially LV)
• LV free wall rupture

Other advance echo techniques may be useful

DYNAMIC LVOT OBSTRUCTION WITHOUT ASYMMETRICAL SEPTAL HYPERTROPHY

• dynamic LVOT obstruction with SAM can occur when ever a hyperdynamic state exists
• can cause cardiogenic shock
• think of this if patient is getting hypotensive when inotropes being turned up!

Risk factors

• elderly
• hypovolaemia
• elderly
• septal bulge
• positive inotropic or vasodilator therapy
• IABP

Management

• volume load
• stop inotropes
• increase afterload (e.g. phenylephrine)

References and Links

LITFL

• ECG Library – Takotsubo Cardiomyopathy
• ECG Library – Restrictive Cardiomyopathy
• ECG Library – Hypertrophic Cardiomyopathy (HCM)
• ECG Library – Dilated Cardiomyopathy (DCM)
• Ultrasound Top 100 – Case 091

Journals

• Losi MA, Nistri S, Galderisi M, Betocchi S, Cecchi F, Olivotto I, Agricola E, Ballo P, Buralli S, D’Andrea A, D’Errico A, Mele D, Sciomer S, Mondillo S; Working Group of Echocardiography of the Italian Society of Cardiology. Echocardiography in patients with hypertrophic cardiomyopathy: usefulness of old and new techniques in the diagnosis and pathophysiological assessment. Cardiovasc Ultrasound. 2010 Mar 17;8:7. PMC2848131.
• Wood MJ, Picard MH. Utility of echocardiography in the evaluation of individuals with cardiomyopathy. Heart. 2004 Jun;90(6):707-12. PMC1768248.