Case Author: Atif Qasim, M.D.

Severely Dilated Cardiomyopathy Case

Parasternal Long Axis

2D view

The left ventricle seen in this parasternal long axis view is massively dilated and poorly functioning. This degree of LV dilation tells us this is chronic process. Also note the early closure of the aortic valve from low cardiac output. Echo "smoke" can be seen within ventricle, a sign of slow flowing blood and low cardiac output.

 

Severely Dilated Cardiomyopathy Case

Parasternal Long Axis

M mode through mitral valve

An M-mode through the mitral leaflets shows the classic B bump, an extra hump after the A wave. This suggests elevated LVEDP. Also note the E point septal separation (ESS) is >1 cm, another classic M-mode finding in a dilated cardiomyopathy.

Severely Dilated Cardiomyopathy Case

Parasternal Long Axis

LV dimension measurement

Formal 2D measurements show the LV dimension in diastole is 7.3 cm, which is markedly dilated. Normal LV diastolic diameter is less than 5.6 cm. Also note here how dilated the coronary sinus is (seen under the posterior mitral leaflet), consistent with elevated right sided pressures as well.

Severely Dilated Cardiomyopathy Case

Parasternal Long Axis

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Color Doppler of the mitral valve

Color Doppler through the mitral valve shows mitral regurgitation. This is expected given the marked dilation of the ventricle and mitral annulus. The MR ultimately is graded as moderate to severe based on additional views.

Severely Dilated Cardiomyopathy Case

Parasternal Long Axis

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RV inflow, 2D view

Note how it is difficult to get a true RV inflow view involving just the right ventricle since the LV is so dilated. Here we see some tricuspid regurgitation with color Doppler.

Severely Dilated Cardiomyopathy Case

Parasternal Long Axis

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PA long axis, 2D view

One can see here the that pulmonary artery is dilated, likely from long standing elevated left sided pressured leading to elevated pulmonary pressures.

Severely Dilated Cardiomyopathy Case

Parasternal Long Axis

PA long axis, pulsed wave Doppler

There is also some pulmonic regurgitation as shown here by the PW Doppler through the pulmonic valve. The PA diastolic pressure can be estimated using the pressure at end diastole and RA pressure with CW Doppler.

Severely Dilated Cardiomyopathy Case

Parasternal Short Axis

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Mitral Valve, color Doppler

This parasternal short axis at the mitral level again demonstrates how dilated and hypokinetic the left ventricle is. This view shows color flow from mitral regurgitation.

Severely Dilated Cardiomyopathy Case

Parasternal Short Axis

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Mid-ventricle, 2D view

This is a view at the mid-ventricle level in parasternal short axis. Notice how far apart the two papillary muscles are. All walls: anterior, lateral, inferior and septum appear hypokinetic here.

Severely Dilated Cardiomyopathy Case

Apical 4 Chamber

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2D view

This apical 4 chamber view gives one an appreciation for exactly how dilated the left ventricle is compared to the right ventricle, which also has reduced function.

Severely Dilated Cardiomyopathy Case

Apical 4 Chamber

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Mitral valve, color Doppler

The mitral regurgitant jet is now seen to hug part of the lateral atrial wall. Quantitation of mitral regurgitation is discussed elsewhere, but this is considered moderate to severe mitral regurgitation.

Severely Dilated Cardiomyopathy Case

Apical 4 Chamber

Mitral inflow, pulsed wave Doppler

The mitral inflow filling pattern is pseudonormalized with a large E wave and smaller A wave but low tissue Doppler velocities as shown in the next slide, suggesting that the left atrial pressure is markedly elevated.

Severely Dilated Cardiomyopathy Case

Apical 4 Chamber

Lateral mitral annulus tissue Doppler

Note how low the E' wave velocities are (less than 5cm/sec) suggesting diastolic dysfunction.

Severely Dilated Cardiomyopathy Case

Apical 4 Chamber

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Right ventricle, 2D view

Slight angulation allows a better view of the RV which has moderately decreased function. Notice how little the tricuspid valve annulus moves toward the apex in systole.

Severely Dilated Cardiomyopathy Case

Apical 4 Chamber

Tricuspid regurgitation, continuous wave Doppler

This view shows the tricuspid regurgitant jet and that PA pressures are elevated at 33 mmHg + RA pressure (estimated at 20 mmHg below) = 53 mmHg.

Severely Dilated Cardiomyopathy Case

Apical long axis

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2D view

In this apical long axis view, similar structures are seen as with the PLAX view except now we can also see the apex. Note again the LV smoke seen with low cardiac output state. The EF was ultimately assessed to be about 5-10%.

Severely Dilated Cardiomyopathy Case

Subcostal View

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IVC, 2D view

Here note the dilated IVC which doesn't compress with inspiration, suggestive of high right atrial pressure, in this case estimated at 20 mmHg.

Severely Dilated Cardiomyopathy Case

Parasternal Long Axis

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Summary of Findings

The ventricle is severely dilated with severely decreased function that is not regional. EF estimated at 5-10%. There is moderate to severe mitral regurgitation and tricuspid regurgitation with a PA pressures estimated at 53mmHg. The RV also has mild dilation with moderately decreased function. There is moderate diastolic dysfunction with a pseudonormal pattern.