LESSON 3: DILATED CARDIOMYOPATHY ECHO PARAMETERS

Name 8 2D FINDINGS IN DCM

1. LV size

2. What happens to the mass in the LV

3. What shape configuration of the LV?

4. what happens to the global LV systolic function ?

5. what 3 things can you use to see that^?

6. what may be present?

• Left ventricular enlargement

• Increased Left Ventricular Mass

(reflects a heart attempting to compensate for damage by stretching and growing to maintain its ability to pump blood, eccentric hypertrophy.)

• Spherical configuration of the LV

• Decreased global LV systolic function indices

(indicate that the heart's main pumping chamber (the left ventricle) is weak and cannot effectively squeeze oxygen-rich blood to the body.)

• EF

• Global Longitudinal Strain

(a sensitive echocardiographic measurement that quantifies the percentage of shortening (deformation) of the heart's left ventricle muscle fibers from base to apex during systole.)

• Fractional Shortening

• RWMAs may be present (most of the time aren’t affected by CAD)

name 5 2D SECONDARY FEATURES OF THE LEFT SIDE

1. there will be possible what especially at the LV apex?

2. evidence of ventricular what? (what movement - hint)

3. abnormal what motion due to what delay?

4. what happens to the MV annulus and coaptation of the MV leaflets

5. what is seen of the MV leaflets due to what?

6. what is another important measurement in PLAX???????????

• Possible mural thrombus, especially at the LV apex

• Evidence of ventricular dyssynchrony

• Abnormal septal motion due to conduction delay

• Dilated MV annulus and incomplete coaptation of the MV leaflets

• Tethering or tenting of MV leaflets due to LV remodeling

(secoundary & functional)

(LVID?)

Name 2D SECONDARY FEATURES OF THE RIGHT SIDE

1. size of the atria

2. size of the RV

3. may exhibit _____ RV function

4. list 5 measurements made for the RV function

5. what happened to the IVC with _____inspiratory collapse

• Enlarged atria

• Right ventricular enlargement

• May exhibit decreased RV function (measured by the following)

• FAC %

• S’

• TAPSE

• RV strain

• RV 3D EF

• Dilated IVC with reduced inspiratory collapse

What happens with the Mass in DCM, explain:

Even though we have ______ to _____ walls the heart must accommadte to the volume _____ flow in order to do this it increases its _____

increased ___ comes from combination of ventricular ________ and _______ muscle ______

Even though we have normal to thin walls the heart must accommadate the volume over flow in order to do this it increase its mass,

increased mass comes from combination of ventricular didilatation and enlarge muscle cell

LV mass is increased in DCM

Increased LV mass = more total LV muscle/tissue than normal. In DCM, this often happens with LV enlargement/dilation, but LV mass is not the same as LV size; size is the chamber dimension, mass is the amount of myocardium.

LV MASS: LINEAR METHOD

what are the three things we use here and when do we measure?

IVS- Interventricular septum

LVID- LV inner diameter

PWT- posterior wall thickness

Measured in end diastole

what happens to the LVID- LV inner diameter in DCM pt

LVID increase above normal limits in DCM

what is the linear method formula ?

what type of hypertrophy does DCM have?

Eccentric Hypertrophy

SPHERICITY INDEX

what is it used to evaluate?

how do you calculate ?

what is it a predictor of in DCM patients?

To evaluate the shape of the LV

• Calculation of the ratio between ED length and width

• Predictor of survival in DCM patients

SPHERICITY INDEX

what number tell’s us it is poor prognosis?

A perfect sphere will be what number ?

<1.5 is poor prognosis

• A perfect sphere will equal 1

Tell me 3 ways we can determine LV SYSTOLIC FUNCTION?

EF measured by 2D Biplane method (4 & 2 chamber)

GLS

FRACTIONAL SHORTENING (FS%)

what is the EF formula, and how is the EF usally in DCM pt?

EF= (EDV-ESV)/EDV

EF is low in DCM pt (40-30 % severly abnormal)

Slove EF%

Example

4C EDV = 130 mL

4C ESV = 60 mL

2C EDV = 110 mL

2C ESV = 50 mL

EDV = 130 + 110 / 2 = 120 mL

averaged ESV = 60 + 50 / 2 = 55mL

120 - 55 / 120 = 65 / 120 × 100 = 54%

what is the normal value for GLS?

Normal value ≤ -18%

what is the formula for FRACTIONAL SHORTENING?

FS% = (LVEDD-LVESD/LVEDD) x 100

What is the normal % for FRACTIONAL SHORTENING

Normal 25-35%

Practice Problem: Fractional Shortening

A patient has:

LVEDD = 6.0 cm
LVESD = 4.8 cm

Calculate the FS%.

FS% = [(LVEDD − LVESD) / LVEDD] × 100

Work:

FS% = [(6.0 − 4.8) / 6.0] × 100
FS% = (1.2 / 6.0) × 100
FS% = 0.20 × 100
FS% = 20%

Answer: FS = 20%

Interpretation:
Normal FS is about 25–35%, so 20% is reduced, suggesting decreased LV systolic function in DCM.

What suggests LV systolic function seen in dilated CM?

A reduced FS suggests LV systolic function seen in dilated CM

A reduced FS suggests LV systolic dysfunction.”

FRACTIONAL SHORTENING is less accurate in what two things?

• RWMAs

• LV dilation/ remodeling

whats more accurate way of finding EF is it using the FS% or Biplane method?

Biplane method

LV DIASTOLIC FUNCTION

What do we need? (things we need to assess / obtain while scanning?) name 5

• Pulmonary veins

• MV inflow PW

• MV annulus TDIs

• LAVi

• TR

LV DIASTOLIC FUNCTION

what are two things that are associated with this (patho and hemodyanmics)

name 2, what is typically the grade? what happens to the ventricle and LVEDP?

• Typically grade II or greater

• Stiff noncompliant ventricle increases the LVEDP

what RWMA’S do we see with DCM?

“Global hypokinesis with severely reduced LV systolic function”

what does “Global hypokinesis mean (meaning as in the segments of the heart whats going on with them?)

All segments of the heart are reduced uniformly

RWMA’S:

typical cause..? DCM is the most common form of what?

non ischemic cardiomyopathy (due too myocardial disease not cause by CAD, but not all non ischemic cardiomyopathy is DCM other things that can cause it)

“Typical cause: non-ischemic cardiomyopathy” means:

When the LV is weak everywhere equally — called global hypokinesis — it is more typical of non-ischemic cardiomyopathy.

Non-ischemic means the weakness is not mainly from blocked coronary arteries or a heart attack.

When RWMAs can be seen in a DCM looking heart

what are the other factors we can see, name 4

^if the heart looks like DCM but you see regional wall motion abnormalities, think about an underlying cause.

RWMA suspect a primary or secoundary causes?

Ischemic cardiomyopathy = poor blood flow/CAD caused damage (artery clog)
Prior MI with remodeling = old heart attack damaged one region, then LV remodeled/dilated
Myocarditis = inflammation damaged parts of the myocardium
Pacing induced/LBBB DCM = electrical delay causes abnormal contraction pattern

These are considered secondary causes because something else damaged that region of myocardium.

Simple flashcard:
RWMAs suspect a secondary cause
DCM usually causes global hypokinesis
That means the whole LV is weak everywhere, kind of evenly.

But RWMA = regional wall motion abnormality
That means only certain walls/segments are moving poorly, while other areas may move better.

So your teacher is saying:

If the LV looks dilated like DCM but only certain regions are abnormal, that may suggest the DCM appearance is from a secondary cause, such as:

Ischemic cardiomyopathy = poor blood flow/CAD caused damage
Prior MI with remodeling = old heart attack damaged one region, then LV remodeled/dilated
Myocarditis = inflammation damaged parts of the myocardium
Pacing induced/LBBB DCM = electrical delay causes abnormal contraction pattern

The key line is: “RWMAs suspect a secondary cause.” That means RWMAs make you think, “Why is only part of the ventricle abnormal?” instead of simple non-ischemic DCM where the weakness is usually more global.

what does Spontaneous echo contrast tell you

LV smoke

describe what LV smoke is?

Temporary RBC ______occurring in fresh blood in a ____flow state

____flow sate causes concern for what?

what does it cause’s a concern for? name 3

Temporary RBC clumping occurring in fresh blood in a low flow state

• Low flow sate causes concern for thrombus formation

• LV thrombus & Mural or Apical thrombus

when we see LV smoke what should we used and espically when what?

Always use Definity contrast with poor endocardial definition and/or EF<30%.

what does DYSSYNCHRONY mean?

The heart muscle does ____ contract in a ____ matter in DCM

The heart muscle does not contract in a uniform matter in DCM

(the septal and lateral wall are not firing at the same rate)

in DYSSYNCHRONY

what does the LV do to affect the conduction pathways, and how is it affected ?

Name two things that are altered?

LV enlargement-longer conduction pathways

• Altered myocyte alignment and calcium handling

( due to the myocardium stretches and remodles in DCM thats why get those longer condution pathways and fire at different rates - thats what dyssynchront is)

Myocytes = heart muscle cells
They are supposed to be organized in a way that helps the LV squeeze efficiently.

Altered myocyte alignment means the muscle cells/fibers are stretched, remodeled, and not lined up as well because the LV is enlarged/dilated.

Calcium handling means how heart cells use calcium to contract and relax. Calcium is like the “signal” that tells the muscle cell to squeeze. If calcium handling is abnormal, the contraction becomes weaker or delayed.

in DYSSYNCHRONY what are the electrical components in the pt name two and what is it associated with?

1. what happens with the QRS

2. what arrthimya is there

3. associated with what function and outcomes

Wide QRS

LBBB (electrical and mechanical dyssynchrony, 30 -40 % common to see in DCM - very common to see

Associated with worse LV function and outcomes

what is this showing?

LBBB

For DYSSYNCHRONY what are the mechanical things we see on echo

1. talk about te LV segments contraction***

2. septal motion

3. apex moves how

1. Different LV segments contract at different times****

2. Early inward septal motion

3. Apex moves side to side

in DCM pt what will be the size of the LA

Will have LA enlargement

In DCM pt what happens to the MV annulus and coaptation of the MV leaflets what does this lead to?

Dilated MV annulus and incomplete coaptation of the MV leaflets leads to MR (secondary/functional MR)

In DCM pt tethering or tenting of MV leaflets due to what?

Tethering or tenting of MV leaflets due to LV remodeling (this secoundary / functional)

what is the MR CONTINUITY EQUATION / Regur volume

SV of MV = MV CSA x MV VTI

SV LVOT = LVOT CSA x LVOT VTI

Regurgitant Volume = SV MV – SV LVOT

MR CONTINUITY EQUATION, what is the regur fraction

MR CONTINUITY EQUATION, what is the EROA?

MR PISA EQUATION & EROA & Regurgitant volume

for the RIGHT HEART , what are findings that you can associated with DCM pt name name 5, and name 5 ways which allow you determine the RV function that can tell us the EF / how well the RV is functioning?

1. there is what due to the backflow of blood

2. what is the size of the atria

3. what is the size of the RV

4. May exhibit _____ RV function

5. What happens with the IVC with ______inspiratory collapse

list 5 measurement

• PHTN (due to the backflow)

• Enlarged atria

• Right ventricular enlargement

• May exhibit decreased RV function

• FAC %

• S’

• TAPSE

• RV strain

• RV 3D EF

• Dilated IVC with reduced inspiratory collapse

TRICUPSID REGURGITAITON

PISA fllow rate formula

EROA

Reg vol

PHTN

What images do we need for assessment? name two and give me the formula that we would use

TR signal

• IVC assessment

• RVSP = 4(TR Velocity)2 + RAP

M-MODE CHARACTERISTICS IN DCM tell me 3

• EPSS >6 MM

• B-BUMP

• DECREASED AORTIC ROOT MOTION AND EARLY AVC (b/c of decreased CO)

what does EPSS > 6 MM tell us? and what does it indicate

Large space between the mitral anterior leafleat and septal wall, indicates a decreased EF

what does the B-Bump tell us?

High LVEDP and LAP

(MV leafleats remain semi open in diastole it occurs b/c the LAP exceeds the LV pressure which prolongs the a wave for a little and thats why you see the b - bump)

Pracrice MATH

MR PISA Radius is 1.0 cm

Aliasing Velocity is 34 cm/s

MR Peak Velocity 480 cm/s

MR VTI 132.2 cm

answer 58 ml