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Home | CCC | Cardiomyopathy Echocardiography

Cardiomyopathy Echocardiography

by Dr Chris Nickson, last update April 22, 2019

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.

CCC 700 6

Critical Care

Compendium

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About Dr Chris Nickson

An oslerphile emergency physician and intensivist suffering from a bad case of knowledge dipsosis. Key areas of interest include: the ED-ICU interface, toxicology, simulation and the free open-access meducation (FOAM) revolution. @Twitter | INTENSIVE| SMACC

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