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Approach to Diagnosis: Echocardiography

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Book cover Hypertrophic Cardiomyopathy

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Abstract

The diagnosis of HCM can be challenging. Echocardiography has become the primary method for the initial evaluation of patients with suspected hypertrophic cardiomyopathy. The integrated utilization of two-dimensional echocardiography, Doppler echocardiography, and stress echocardiography allows for the evaluation of the presence and severity of LV wall thickness, diastolic dysfunction, LVOT obstruction, and mitral regurgitation. Thus, echocardiography offers the clinician a comprehensive imaging modality in those with suspected HCM, as well as those already diagnosed and those undergoing surveillance or therapeutic intervention. In this chapter, we detail the benefits of echocardiography for the diagnosis, monitoring, and management of those with suspected or known HCM.

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Author information

Authors and Affiliations

  1. Division of Cardiology, Department of Medicine, NYU Winthrop University Hospital, Mineola, NY, USA

    Beevash Ray & Matthew W. Martinez

  2. Division of Cardiology, Department of Medicine, Lehigh Valley Health Network, Allentown, PA, USA

    Beevash Ray & Matthew W. Martinez

  3. Sports Cardiology and Hypertrophic Cardiomyopathy Program, Cardiovascular Imaging, Lehigh Valley Health Network, Allentown, PA, USA

    Matthew W. Martinez

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  1. Beevash Ray
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Correspondence to Matthew W. Martinez .

Editor information

Editors and Affiliations

  1. Westchester Medical Center, Valhalla, NY, USA

    Srihari S. Naidu

Questions

Questions

  1. 1.

    What advantage of M-mode echocardiography makes it ideal for measurements in HCM?

    1. A.

      High lateral resolution

    2. B.

      High temporal resolution

    3. C.

      High tissue penetration

    4. D.

      High axial resolution

    Answer: B. The advantage of M-mode echocardiography over other imaging modalities is the very high temporal resolution that it provides. As a result, it allows for the examination of high-frequency motion. For example, subtle abnormalities such as partial mid-systolic closure of the aortic valve due to subvalvular obstruction and systolic anterior motion of the mitral valve are demonstrated best using M-mode echocardiography. The axial resolution of an image is mostly affected by pulse length and frequency. The lateral resolution is affected by beam width, depth, and gain. The depth of penetration is directly related to the wavelength of US.

  2. 2.

    True or False. RV hypertrophy is rare in HCM.

    Answer: False. Right ventricular hypertrophy is often seen in HCM. In one study right ventricular hypertrophy was seen in 44% of known HCM patients. RVH on echo is best seen in the subcostal view. A greater than 5 mm measurement of the RV free wall is associated with RVH.

  3. 3.

    What is a pitfall of using M-mode echocardiography for linear measurements?

    1. A.

      Low temporal resolution

    2. B.

      Poor tissue penetration

    3. C.

      Finding a representative portion of the LV

    Answer: C. Since M-mode echocardiography is essentially an “ice pick” view of the heart, it is often difficult to determine which precise part of the heart is being visualized. Furthermore, M-mode may capture an off-axis cut, thus giving an oblique view of the LV wall. Temporal resolution is highest by M-mode echo.

  4. 4.

    Which of the following is true?

    1. A.

      Classically, LV wall thickness measurements are made at end diastole in the four-chamber view.

    2. B.

      The area of interest for the measurement is only the basal septum.

    3. C.

      Highly trained athlete wall thickness often exceeds 15 mm.

    4. D.

      Extreme wall thickness of greater than 30 mm is associated with sudden cardiac death.

    Answer: D. A greater than 30 mm wall thickness is associated with sudden death and is a Class 2a indication for an implantable defibrillator. The wall thicknesses of highly trained athletes are rarely greater than 15 mm. Typically one measures for LV hypertrophy in the parasternal long or short axis. The four-chamber view is never used. The area of interest is usually the basal septum, but various patterns and distribution of LV hypertrophy (including diffuse and marked) have been reported in HCM.

  5. 5.

    Which of the following statements about echocardiographic left atrial size and HCM is true?

    1. A.

      The left atrium is measured in the parasternal long axis view.

    2. B.

      The preferred measurement for left atrial size is area.

    3. C.

      A left atrial indexed volume of greater than 34ml/m2 has prognostic implications.

    4. D.

      The left atrial volume can only be approximated by 3D echocardiography.

    C. The preferred size measurement for the left atrium is volume indexed by body surface area. 2D echo can be used to approximate left atrial volume by long-/short-axis measurements. These measurements should be done in the four-chamber and two-chamber apical views. A left atrial indexed volume of greater than 34 mL/m2 has been shown to prognosticate more serious cardiovascular events and greater LV hypertrophy, more diastolic dysfunction, and higher filling pressures.

  6. 6.

    In which views are the LVOT gradient checked?

    1. A.

      The apical five-chamber

    2. B.

      The apical three-chamber

    3. C.

      Both a and b

    4. D.

      Neither a nor b

    Answer: C. HCM patients often have LVOT obstruction. It is important to measure gradients properly to ascertain the level and location of the obstruction. The best way to measure LVOT gradients is in the apical four- and five-chamber views. In symptomatic HCM patients who do not have significant pressure gradients at rest, a dynamic obstruction must be investigated.

  7. 7.

    Which of the following is not a recommended parameter to evaluate for diastolic dysfunction grade in HCM patients?

    1. A.

      Pulmonary vein atrial reversal velocity <30 msec.

    2. B.

      E/E’ ratio >14.

    3. C.

      LA volume index of >34 ml/m2.

    4. D.

      Peak velocity of the TR jet >2.8m/sec.

    A. The American Society of Echocardiography established new guidelines for the determination of diastolic dysfunction in 2016. There are now four recommended parameters needed to determine diastolic dysfunction grade. These four parameters are average E/E′ ratio of >14, LA volume index of >34 ml/m2, pulmonary vein atrial reversal velocity time of >30 msec (not <30 msec), and peak velocity of TR jet of >2.8 m/sec.

  8. 8.

    Your patient’s echocardiogram has the following values: E/E′ ratio of 16, LA volume of 37 ml/m2, pulmonary vein reversal velocity time of 25 msec, and TR jet velocity of 2.5 m/sec. What grade diastolic function does the patient have?

    1. A.

      Grade I

    2. B.

      Grade II

    3. C.

      Grade III

    4. D.

      Indeterminate

    Answer: D. The recommended parameters needed to evaluate diastolic dysfunction grade in HCM are average E/E′ ratio of >14, LA volume index of >34 ml/m2, pulmonary vein atrial reversal velocity time of >30 msec, and peak velocity of TR jet of >2.8 m/sec. If less than 50% of the parameters are met, then LA pressure is normal, and grade I diastolic dysfunction is present. If greater than 50% of the parameters are met, then the LA pressure is elevated, and grade II diastolic dysfunction is present. In the situation that exactly 50% of the parameters are met, estimated LA pressures and diastolic grade are indeterminate. Finally, there is grade III diastolic dysfunction in the presence of a restrictive filling pattern (E/A > 2.5, deceleration time of E velocity of <150 msec, and isovolumic relaxation time <50 msec) and reduced E′ velocity. This patient had 50% of the criteria; thus the grade is indeterminate.

  9. 9.

    Contrast echocardiography media plays an important role in hypertrophic cardiomyopathy assessment in all of the following except:

    1. A.

      The evaluation of SAM

    2. B.

      Apical HCM

    3. C.

      Thrombus formation in a “burned-out” reduced LVEF HCM patient

    4. D.

      To identify appropriate coronary vessels for alcohol septal ablation

    Answer: A. Contrast echocardiography plays an important role in HCM evaluation. Often the apical walls are not well visualized on a TTE. The classic spade appearance of the ventricular lumen of an apical HCM patient is well recognized with contrast. In later stages of HCM, one can have severely reduced LVEF. These patients are susceptible to forming LV thrombus which is best identified with contrast. Finally, contrast media is injected into the coronary arteries, to identify and confirm the appropriate septal branch that supplies the myocardium for alcohol septal ablation. It is important to identify the desired area for ablation and to avoid alcohol injection into a papillary muscle or LV free wall. Contrast media does not play a major role in evaluating SAM.

  10. 10.

    TEE is an important tool in HCM evaluation in the following situations except:

    1. A.

      Patient with HCM and concomitant intrinsic degenerative mitral valve disease

    2. B.

      Differentiating HCM from a subaortic membrane

    3. C.

      Intraoperatively during septal myectomy

    4. D.

      Checking LVOT and aortic valve gradients in a patient with HCM and aortic stenosis

    Answer: D. HCM patients often have mitral regurgitation. However, it may be difficult to discern intrinsic mitral valve disease versus MR secondary to SAM in an HCM on a TTE. TEE is the best tool to evaluate for intrinsic mitral valve disease in these patients. Although rare, an important differential of LVOT gradients is subaortic membrane. These are often missed on TTE. Having TEE imaging is a class I indication during intracardiac surgery. HCM evaluation with concomitant AS is often challenging. Checking LVOT and AS gradients in TEE, although possible, is not ideal because it is often difficult to obtain Doppler measurements parallel to flow. TEE can be valuable in these patients when evaluating the aortic valve structure and measuring aortic valve area by planimetry in the setting of high gradients.

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Ray, B., Martinez, M.W. (2019). Approach to Diagnosis: Echocardiography. In: Naidu, S. (eds) Hypertrophic Cardiomyopathy. Springer, Cham. https://doi.org/10.1007/978-3-319-92423-6_4

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  • DOI: https://doi.org/10.1007/978-3-319-92423-6_4

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  • Publisher Name: Springer, Cham

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  • Online ISBN: 978-3-319-92423-6

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