Exam 4 Flashcards
Cardiomyopathy
primary disease of the myocardium excluding myocardial dysfunction due to ischemia or chronic valvular disease
Dilated Cardiomyopathy
all four chambers are enlarged with impaired systolic function of both the LV and RV due to a wide range of underlying causes
Hypertrophic Cardiomyopathy
an autosomal dominant inherited disease of the myocardium related to abnormalities in gene coding for contractile proteins
Restrictive Cardiomyopathy
fibrotic stiff ventricles due to altered myocardium with significantly impaired diastolic function
Causes and symptoms of Dilated Cardiomyopathy
Causes: idiopathic, infections, toxins, metabolic, inherited, Tako-tsubo, autoimmune/systemic inflammatory disease
Symptoms: Dyspnea, orthopnea, DOE, cough, rales, crackles, sputum
Causes and symptoms of Hypertrophic Cardiomyopathy
Causes: inherited
Symptoms: angina, syncope, DOE, Paroxysmal Nocturnal Dyspnea, pulmonary edema
Causes and symptoms of Restrictive Cardiomyopathy
Causes: infiltrative, deposition or scarring to organs, endomyocardial fibrosis, myocardial fibrosis
Symptoms: heart failure due to impaired diastolic filling and inability to maintain cardiac output
5 parameters of Diastolic Algorithm
- Average E/e’ > 14
- Septal e’ velocity < 7 cm/s
- Lateral e’ velocity < 10 cm/s
- TR velocity > 2.8 m/s
- LA volume index > 34 ml/m^2
E/A ratio for Grades 1, 2, and 3
Grade 1: E/A ≤ 0.8 and E ≤ 50 cm/s
Grade 2: E/A ≤ 0.8 and E > 50 cm/s OR E/A > 0.8 - < 2
Grade 3: ≥ 2
Additional Parameters of Diastolic Dysfunction:
Normal
DT: 160-200 ms
E/e’: ≤ 14
AR-A: < 0 ms
IVRT: 50-100 ms
PVA: ≤ 35 cm/s
S~D
L Wave: < 20 cm/s
Propagation Velocity: > 50 cm/s
Additional Parameters of Diastolic Dysfunction:
Grade 1
DT: > 200ms
E/e’: increasing ratio implies worsening
AR-A: < 0 ms
IVRT: > 100 ms
PVA: ≤ 35 cm/s
S significantly > D
L Wave: > 20 cm/s
Propagation Velocity: decreasing slope implies worsening
Additional Parameters of Diastolic Dysfunction:
Grade 2
DT: 160-200 ms
E/e’: increasing ratio implies worsening
AR-A: ≥ 30 ms
IVRT: 50-100 ms
PVA: > 35 cm/s
S<D
L Wave: > 20 cm/s
Propagation Velocity: decreasing slope implies worsening
Additional Parameters of Diastolic Dysfunction:
Grade 3
DT: < 160 ms
E/e’: increasing ratio implies worsening
AR-A: ≥ 30 ms
IVRT: < 50 ms
PVA: > 35 cm/s
S significantly < D
L Wave: > 20 cm/s
Propagation Velocity: decreasing slope implies worsening
DD and age
~ 60 E/A ratio = 1
> 60 E/A ratio = < 1
> 60 increased decel time and IVRT
> 50 S > D
Valsalva and DD
valsalva can convert restrictive LV inflow to a pseudonormal
Corrective Treatments for Dilated Cardiomyopathy
-Periodic Echocardiograms
-Conventional Medications
-Sizing down annulus
-Implantable defibrillators
-BiVent pacemakers
-LVAD and transplant
-MV repair/ reopposing the chordae
Corrective Treatments for Hypertrophic Cardiomyopathy
-Echo
-Medical Therapy
-AICD (Automatic Implanted Cardiac Defibrillator)
-PTSMA (Percutaneous Transluminal Septal Myocardial Ablation)
-Myotomy-Myectomy (cutting of the myocardium)
Corrective Treatments for Restrictive Cardiomyopathy
-treat Underlying Etiology
-treat CHF
-transplant
Patterns of Hypertrophy
Type 1: 10 %, hypertrophy confined to antero septum
Type 2: 20 %, hypertrophy of both antero and infero septum
Type 3: 52 %, hypertrophy of septum and anterolateral free wall
Type 4: 18 %, hypertrophy of other regions, apical hypertrophy “ace of spades”
Doppler Evaluation of LVOT Obstruction
-A5
- PW mapping
- CW mid to late systolic high velocity jet > 1.1 m/s , dagger shaped LVOT envelope
LVOT Obstructions
-Nonobstructive: PPG < 30 mmHg at rest with provocation
-Obstructive: PPG ≥ 30 mmHg at rest
-Inducible or latent: PPG < 30 mmHg at rest and ≥ 30 mmHg with provocation
LVOT Obstruction vs. Midcavitary Obstruction
LVOT:
dagger shaped envelope
mid to late systolic high velocity jet
Midcavitary:
seen in dehydrated patients with LVH
late peaking and sawtooth waveform in PW
alleviated by giving volume
RCM vs. Constrictive Pericarditis
RCM:
- reduced regional and global longitudinal strain
- low medial and septal TDI e’ velocities
- moderate to severe PHT
- low color m-mode propagation velocity
Constrictive Pericarditis:
- treatable
- normal medial strain
- preserved global longitudinal strain “hot septum”
- normal medial TDI e’
- demonstrates significant respiratory changes on doppler inflows
Athletic vs Pathological Heart
Athletic:
-mild LVH or RVH
- mild RVE, LVE, LAE, or IVC enlargement
- reverses with deconditioning
- normal TDI and strain
Common Conditions of Diastolic Dysfunction
-Primary Myocardial: Dilated, Restrictive, and Hypertrophic Cardiomyopathy
-Secondary Myocardial: Hypertension, Aortic Stenosis, Congenital Heart Disease
-Coronary Artery Disease: Ischemia, Infarction
-Extrinsic Constraint: Pericardial Tamponade, Pericardial Constriction
Typical Grade 1 of Diastolic Dysfunction (Impaired LV relaxation)
- decreased E/A ratio
- prolonged deceleration time
- reduced e’
- increased LA volume
- increased TR velocity
- increased IVRT
- S > D
Typical Grade 2 of Diastolic Dysfunction (Pseudonormal Diastolic Dysfunction)
- Normal E/A ratio
- Normal deceleration time
- Normal IVRT
- elevated E/e’
- reduced E’
- increased LA volume
- increased TR velocity
- S slightly less than D
Typical Grade 3 of Diastolic Dysfunction (Abnormal Ventricular Compliance)
- increased E/A ratio
- decreased deceleration time
- reduced E’
- increased LA volume
- increased TR velocity
- elevated E/e’
- reduced IVRT
- pulmonary vein AR wave prolonged
- S significantly < D
2D/M-mode/Doppler findings in Dilated Cardiomyopathy
2D: - significant 4 chamber enlargement, LVIDd > 112%, LVED > 75ml/m^2 , increased LV mass, spherical shaped LV
M-mode: - increased EPSS, decreased aortic root motion, B bump, tapered aortic valve closure
2D/M-mode/Doppler findings in Hypertrophic Cardiomyopathy
2D: asymmetric hypertrophy of LV, “ace of spades” appearance
M-mode: systolic anterior motion of anterior mitral leaflet
2D/M-mode/Doppler findings in Restrictive Cardiomyopathy
2D: thickened to fibrotic appearance of ventricular walls, biatrial enlargement, small ventricles
Doppler: MR/TR envelopes may begin at end diastole
2D/M-mode/Doppler findings in Amyloid
2D: myocardium, valves, and IAS appear thick and granular in appearance, biatrial enlargement
2D/M-mode/Doppler findings in LVOT Obstruction
2D: systolic anterior motion of anterior mitral leaflet, contact lesion on septum, posterior jet of MR
M-mode: mid-systolic fluttering and closing of AV
Doppler: mid to late systolic high velocity jet, dagger shaped envelope, in PW mapping will determine location of obstruction
2D/M-mode/Doppler findings in Hypertension
2D: LV dilation, aortic root dilation, aortic valve sclerosis, LAE, mitral annular calcification
Doppler: mid cavitary obstruction = late systolic high velocity sawtooth signal
2D/M-mode/Doppler findings in Diabetes
2D: thick ventricular walls, myocardium is reflective/hyperechoic, LVE, LVH
Doppler: abnormal strain and TDI
2D/M-mode/Doppler findings in Rejected Post transplanted heart
2D: RV/LV systolic dysfunction, increased LV mass, increased echogenicity of myocardium, evolving pericardial effusion
