Echocardiography in Hypertrophic CardiomyopathyThe Role of Conventional and Emerging Technologies
Luis C. Afonso, MD, FACC*,
Juan Bernal, MD*,
Jeroen J. Bax, MD ,
Theodore P. Abraham, MD, FACC ,*
* Division of Cardiology, Wayne State University, Detroit, Michigan
Division of Cardiology, University of Leiden, the Netherlands
Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
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Figure 1 Characteristic Echocardiographic Features of Obstructive HCM
(A) Parasternal long-axis view depicting severe asymmetric septal hypertrophy and systolic anterior mitral valve motion (arrowhead); (B) M-mode across the mitral leaflets depicting prominent systolic anterior motion (thick arrows) of the anterior mitral leaflet (SAM); (C) M-mode tracing across the aortic valve demonstrating partial closure of aortic leaflets (arrowheads); and (D) accentuation of late-peaking dynamic left ventricular outflow tract obstruction after the Valsalva maneuver. Ao = aorta; HCEM = hypertrophic cardiomyopathy; IVS = interventricular septum; LA = left atrium; SAM = systolic anterior motion; PW = posterior wall ratio
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Figure 2 Tissue Doppler Imaging (TDI) and TDI-Derived Strain Assessment in Patients With HCM
(A) Myocardial tissue Doppler velocity tracings from 4 representative regions of interest (ROIs) in a patient with HCM. Note significantly attenuated systolic and early diastolic velocities from disparate ROIs in the septum. (B) Tissue Doppler-derived longitudinal strain curves in the same areas shown in (A) and corresponding parametric color strain map. Note positive longitudinal strain (systolic lengthening) or "paradoxical strain" (blue and green tracings) in 2 of the 4 depicted ROIs (basal septum) and attenuated longitudinal strain elsewhere (yellow tracing). Note striking heterogeneity of strain tracings in contrast to tissue Doppler data. AVO = aortic valve opening, AVC = aortic valve closure; other abbreviations as in Figure 1.
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Figure 3 Echocardiographic Diagnosis of Apical Hypertrophic Cardiomyopathy
(A) Contrast-enhanced images (Definity; Bristol-Myers Squibb Medical Imaging Inc., North Billerica, Massachusetts) of a patient with apical hypertrophic cardiomyopathy in end-diastole and (B) "ace of spades" appearance of the left ventricle cavity with apical cavity obliteration in end-systole. (C) Conventional apical 4-chamber view showing exuberant LVH (arrow) in apical HCM. (D) Two-dimensional strain (quad format) images of same patient showing paradoxical apical longitudinal strain (crimson segment and tracing) and corresponding perturbations in the color M-mode of the parametric strain map. Note loss of base-apex (strain) gradient.
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Figure 4 Three-Dimensional Echocardiography
Still frame of a parasternal long-axis view obtained using real-time 3-dimensional imaging, angulated to depict systolic anterior motion of the anterior mitral leaflet (SAM) in a patient with obstructive HCM. Abbreviations as in Figure 1.
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Figure 5 Proposed Algorithm for the Diagnosis and Risk Stratification of Patients With Suspected HCM
*Mean transverse LA diameter; **difference between the longest and shortest Q-Sm time intervals (beginning of Q-wave in ECG to onset of systolic annular motion by TDI) among 4 different LV basal myocardial segments. HCM = hypertorphic cardiomyopathy; IVS/PW = interventricular septum/posterior wall ratio; LA = left atrial; LAVI = left atrial volume index; LV = left ventricular; LVH = left ventricular hypertrophy; LVOT = left ventricular outflow tract; RT-3DE = real time-3 dimensional echocardiography; SAM = systolic anterior motion; TDI = tissue Doppler imaging; 2D-strain = 2 dimensional speckle tracking imaging.
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