Trabecula In Lv Echocardiogram

(with severe hypertrophy)

Doppler

• Relaxation abnormality/diastolic

findings

dysfunction

Hocm Left Ventricle
Fig. 32. Apical hypertrophic cardiomyopathy vs left ventricular (LV) noncompaction. The apical variant of hypertrophic cardiomyopathy should not be confused with LV noncompaction. The latter exhibits a spongiform appearance-reflecting deep tra-beculations within the endocardium.

can provide more accurate estimates of left ventricular mass and LVH.

Patterns of hypertrophy other than concentric LVH can occur in hypertension and the extent and geometric appearance is related to the duration, the severity, and the nature of the hemodynamic load. Diastolic dysfunction is seen in LVH owing to hypertension, but the earliest echocardiographic signs in hypertension (without LVH) are lower E/A ratios and longer isovolumic relaxation times. Hypertension commonly co-exists with diabetes, and both conditions cause diastolic dysfunction, even when the diagnosis is subclinical.

miscellaneous cardiomyopathy

Left Ventricular Noncompaction

Left ventricular noncompaction is a rare unclassified cardiomyopathy with markedly prominent apical trabeculae with deep intertrabecular recesses (Fig. 32). These are best visualized on color flow Doppler of the left ventricle using apical windows. The trabecula-tions have a spongy appearance on short axis views and should not be confused with intracavitary thrombi. (Fig. 33; please see companion DVD for corresponding video). Left ventricular noncompaction may present in childhood or later adulthood. The prognosis is generally poor. Associated intracavitary thrombi and embolic complications have been reported in the setting of systolic dysfunction.

Stress-Related Cardiomyopathies

There is renewed interest in a peculiar form of dilated cardiomyopathy initially described in Japan and named "takotsubo" (Japanese for octopus trap—Fig. 34) for its echocardiographic appearance (Fig. 35; please see companion DVD for corresponding video). It occurs in stressful states and predominantly affects women. Stress or stress-related cardiomyopathies include those named "transient myocardial stunning owing to sudden emotional stress" and "acute reversible cardiomyopathy provoked by stress." These are helpful clinical terminologies, but transient apical ballooning best describes the morphological and temporal presentation.

Stress cardiomyopathies mimic acute myocardial infarction and acute coronary syndromes, but a constellation of features help to draw the distinction (Table 15). Echocardiographic features in the acute phase show marked apical hypokinesis-akinesis with compensatory hyperkinesis of the basal left ventricular segments, resulting in a balloon-like apex during systole Recovery of normal function within 4 wk of presentation is typical. A not-too-dissimilar picture occurs in some patients with proven myocardial infarction who recover normal ventricular function on serial echocar-diographic examination.

Parasternal Long Axis View And Segments

Fig. 33. Left ventricular noncompaction. Parasternal long-axis images from a 41-yr-old female whose initial presentation was heart failure in pregnancy shows evidence of systolic impairment (noncompaction) that results from exuberant apical trabeculations (arrows, A). Parasternal short-axis view shows a similar appearance (arrows, B). Color Doppler application to the left ventricular region reveals deep intertrabecular recesses within the markedly thickened endocardium (C). Apical long axis view shows the localized distribution of the pathology vis-à-vis apical and mid-inferior regions of the left ventricle (D). (Please see companion DVD for corresponding video.)

Fig. 33. Left ventricular noncompaction. Parasternal long-axis images from a 41-yr-old female whose initial presentation was heart failure in pregnancy shows evidence of systolic impairment (noncompaction) that results from exuberant apical trabeculations (arrows, A). Parasternal short-axis view shows a similar appearance (arrows, B). Color Doppler application to the left ventricular region reveals deep intertrabecular recesses within the markedly thickened endocardium (C). Apical long axis view shows the localized distribution of the pathology vis-à-vis apical and mid-inferior regions of the left ventricle (D). (Please see companion DVD for corresponding video.)

Trabecula Echo
Fig. 34. Transient apical ballooning: Takotsubo.

Arrhythmogenic Right Ventricular Cardiomyopathy (Dysplasia)

Arrhythmogenic right ventricular cardiomyopathy (dysplasia) ARVD/ARVC is a rare cardiomyopathy characterized by progressive fibro-fatty replacement of right ventricular myocytes. It is diagnosed on the basis of the clinical presentation, the ECG, noninvasive imaging (Table 16) and magnetic resonance imaging,

Fig. 35. Transient myocardial stunning: stress-related Takotsubo: transient left apical ballooning. Apical four-chamber views in this 62-yr-old female who presented with chest pains show akinetic apical segments, markedly hypokinetic mid-ventricular segments, with preserved basal segments—a pattern not consistent with coronary artery anatomy. Work-up for acute myocardial infarct— enzymes, electrocardiogram, and cardiac catheterization—were nondiagnostic. Follow-up echocardiogram 6 wk later showed normal cardiac function. (Please see companion DVD for corresponding video.)

Table 15

Stress-Related Cardiomyopathies: Echocardiographic Findings: A Summary

Modality Findings

Two-dimensional findings • Apical akinesis or dyskinesis ("apical ballooning"); moderate-to-severe dysfunction at midventricular level; preserved basal systolic function; overall severe left ventricular dysfunction (median ejection fraction ~20%); rapid resolution of ventricular dysfunction at 2-4 wk

Other • Female preponderance; emotional stress (exaggerated sympathetic stimulation); elevated plasma catecholamines (T2-3X values seen in myocardial infarction); electrocardiogram changes (QT, T-wave); minor elevation in cardiac enzymes (e.g., troponin I); normal coronary arteries/no fixed stenoses (angiography)

End-diastöle

Systole

A43 I Systole |

A43 I Systole |

and histological examination of right ventricular biopsies (Fig. 36 [please see companion DVD for corresponding video] and Table 16). Some cases exhibit strong familial

(autosomal dominant mode of inheritance) and is more common in males and in young adulthood. It is a cause of sudden cardiac death in athletes.

Echocardiography

Fig. 36. Transthoracic echocardiography in this 37-yr-old male who presented with recurrent episodes of tachycardia were normal except for moderate right ventricular dilatation with decreased right ventricular function (A,B). Magnetic resonance imaging (MRI) scan (using fat saturation mode, B, insert) showed moderate right ventricle dilatation, decreased right ventricular systolic function, dyskinesis of the basal free wall of the right ventricle, and a highlighted area indicating fatty replacement (arrow). MRI image courtesy Raymond Kwong, MD, Brigham and Women's Hospital. (Please see companion DVD for corresponding video.)

Fig. 36. Transthoracic echocardiography in this 37-yr-old male who presented with recurrent episodes of tachycardia were normal except for moderate right ventricular dilatation with decreased right ventricular function (A,B). Magnetic resonance imaging (MRI) scan (using fat saturation mode, B, insert) showed moderate right ventricle dilatation, decreased right ventricular systolic function, dyskinesis of the basal free wall of the right ventricle, and a highlighted area indicating fatty replacement (arrow). MRI image courtesy Raymond Kwong, MD, Brigham and Women's Hospital. (Please see companion DVD for corresponding video.)

Table 16

Arrhythmogenic Right Ventricular Cardiomyopathy: Summary of Echocardiographic Findings

Modality

Description

Two-dimensional findings

Doppler findings

Comment

Right ventricle dilatation; right ventricular free wall hypokinesis

Tricuspid regurgitation and increased right heart pressures (with right heart failure)

Magnetic resonance imaging, can present with ventricular tachycardia with left bundle branch block contour, right axis deviation, T-wave abnormalities or supraventricular arrhythmias suggested reading

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Responses

  • lena
    What is trabeculae echos?
    10 months ago
  • ALAN SIROIS
    Are apical trabeculae normal on echo?
    7 months ago
  • abelardo
    What is apical hypokinesis?
    5 months ago

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