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.
Critical Care
Compendium
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