3 Evaluation of the Patient with Diastolic Dysfunction
Restrictive Cardiomyopathy
Background
Site of Involvement | Classification |
---|---|
Myocardium | Noninfiltrative |
TABLE 3-2 OVERALL ECHOCARDIOGRAPHIC APPROACH FOR ASSESSING DIASTOLIC DYSFUNCTION
Modality | View/Technique | Findings |
---|---|---|
2D | Apical, parasternal, subcostal | |
Pulsed wave Doppler | 4-chamber: Ultrasound beam aimed at an angle of 20 degrees laterally to apex, and the sample volume between the tips of the mitral valve leaflets | |
Suprasternal short-axis | ||
Subcostal | ||
Tissue Doppler imaging | 4-Chamber: 2-mm sample volume at the medial mitral annulus with the Doppler beam parallel to the longitudinal movement. Gain settings and wall filters should be low and velocity scale expanded. | Varying E, E/E patterns (see text for details) |
TABLE 3-3 Approaches and Findings in RCM
Modality | General Findings | Specific Findings |
---|---|---|
Chest radiograph | Normal-sized heart. Dilated atria. Signs of pulmonary congestion or interstitial edema. Pleural effusion may occur. |
Mediastinal lymphadenopathy; pulmonary parenchymal disease in sarcoidosis. |
Electrocardiogram | Nonspecific ST- and T-wave abnormalities. Conduction abnormalities. Same chamber and wall dimensions and functions as in echocardiography. |
Low voltage in precordial leads is seen in ~50% of patients with amyloidosis with cardiac involvement. Pseudo-infarct pattern (QS wave in consecutive leads) is seen in ~50% of patients with cardiac amyloidosis. Fibrosis caused by cardiac sarcoidosis can be detected with late gadolinium enhancement. Trilaminar appearance (normal myocardium, thickened fibrotic endocardium, and overlying thrombus) may be detectable in endomyocardial diseases. Global reduction in T2* cardiac tissue is commonly seen in hemochromatosis. |
CT | Same chamber and wall dimensions and functions as in echocardiography. | |
Biposy | In most cases nonspecific. | Apple-green birefringence, electron microscopy findings in amyloidosis. |
Radionuclide imaging | Mainly nonspecific findings in RCM. | With increased cardiac involvement in amyloidosis, Tc-99m labeled tracers are detectable. |
Cardiac catheterization | Nonspecific findings of diastolic dysfunction (increased diastolic pressures, right-sided square root sign, and often LVEDP ≥5 mm Hg greater than RVEDP). |
LVEDP, LV end-diastolic pressure; RVEDP, RV end-diastolic pressure; Tc-99m, 99-mtechnetium.
Echocardiographic Approach
General characteristic findings in RCM include (Figures 3-2 through 3-5):
Specific Diagnoses
Anatomic Imaging (Acquisition/Analysis/Pitfalls)
Endomyocardial Fibrosis
Key Points
Hypertrophic Cardioymopathy
Key Points
Dynamic LV Outflow Tract (LVOT) Obstruction
Mitral Regurgitation
Diastolic Filling Patterns
Overview of Echocardiographic Approach
Acquisition
Wall Thickness
LVOT Obstruction
Analysis/Pitfalls
A number of echocardiographic parameters (2D, M-mode, TDI, and strain) have been demonstrated to have diagnostic value in HCM.6
Differential Diagnosis
Alternative Approaches
Estimating Clinical Prognosis
RCM versus Constrictive Pericarditis
Approach
Monitoring Effects of Treatment
Control of Blood Pressure (BP)
Mass
Diastolic Function
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