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

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.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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