Download DCM

Staff Lecture (2012년 8월 23일)
Role of Echocardiography
in Dilated Cardiomyopathy
Kyung Hee University Hospital
Cardiovascular Center
Woo-Shik Kim
Dilated Cardiomyopathy (DCM)
DCM can be characterized by
dilation and reduced
contraction of left ventricle or
both left ventricle (LV) and
right ventricle (RV)
Diagnostic Evaluation
Heart failure by history and examination
Echocardiography
LVEF ≥ 50%
LVEF < 45%
Rule out aortic stenosis, HT,
hypertrophic CMP
Doppler echocardiography
Non-dilated LV
LVEDD >112%
Work-up for DCM
Role of Echo in DCM
1) accurate and complete diagnosis
2) high-risk features & prognosis
3) guiding therapeutic interventions
Etiology of DCM
Kasper EK et al. JACC 1994:23:586
Etiology of DCM
• Idiopathic
• Sepsis
• Familial
• Doxorubicin toxicity
• Peripartum
• Takycardia induced
• Takotsubo syndrome
• Myocarditis from immune or viral causes
• Extensive ischemic heart disease
• Noncompaction
• Sarcoidosis
Case 1
• 남자, 20세
• ROTC 신검 후 정밀검사 위해 내원
• 증 상 : 없음
• 청 진 : no murmur
Case 1
M/20
Case 1
M/20
Case1 (M/20) EF=45%, LVEDV/LVESV = 199 / 109 ml
Accurate and complete diagnosis
Idiopathic DCM
• Prevalence : 40 per 100 000 persons (USA)
• Genetic factors : >25% of cases
autosomal dominant
This has important implications for screening
of first-degree relatives
• LV dilatation and/or LV dysfunction
Accurate and complete diagnosis
Familial DCM
One individual diagnosed with idiopathic DCM in a
family, with at least:
• one relative also diagnosed with idiopathic DCM
-or• one first-degree relative with an unexplained sudden
death under the age of 35 years.
Example of a family history with autosomal dominant transmission, the
most common mode of inheritance for familial DCM
Ku, L. et al. Circulation 2003;108:e118-e121
Accurate and complete diagnosis
Valve disease
• Chronic LV volume or pressure overload
d/t valvular pathology
→ LV dilatation & dysfunction
• Obvious management implications
→ corrective surgery
Case 2
Aortic stenosis
(low flow / low gradient AS)
Peak velocity = 3.6 m/s
Mean PG = 29 mmHg
Case 2
Dobutamine echo (1)
Case 2
LVO
T
flow
Aortic
flow
Dobutamine echo (2)
(LVOT/AV = 0.16)
(LVOT/AV = 0.17)
Baseline
Peak
PV= 0.4 m/s, TVI=12 cm
PV= 1.0 m/s, TVI=16 cm
Baseline
Peak
PV= 3.6 m/s, TVI=71 cm
PV= 5.4 m/s, TVI=95 cm
Accurate and complete diagnosis
Cardiomyopathies
HCM
DCM
ARVC
RCM
Unclassified
European Guideline
• Left ventricular non-compaction
• Takotsubo cardiomyopathy
Accurate and complete diagnosis
LV non-compaction
LVNC is characterized by prominent trabeculations on the
endocardial surface of the LV with deep recesses extending into
the LV wall
LV non-compaction (DDx)
DDX) Prominent normal myocardial trabeculations
False tendons and aberrant bands
Cardiac tumors
LV apical thrombus
Hypertrophic cardiomyopathy
Case 3
M / 59
Case 3
M / 59
Accurate and complete diagnosis
Takotsubo cardiomyopathy
Case 4
F / 53
Assessing Prognosis in DCM
Assessing High Risk Features & Prognosis in DCM
LV size and systolic function
LV dysfunction has long been regarded as the main
determinant of clinical symptoms, functional class, and
prognosis
• Eyeball
• Biplane modified Simpson’s rule
• Contrast agents
• 3D echo
Assessing High Risk Features & Prognosis in DCM
Case 5 (male / 57 y, 2008)
Assessing High Risk Features & Prognosis in DCM
Biplane modified Simpson’ s rule
4C
Diastole
4C
Systole
2008
EF = 29%
LVEDV = 169 ml
2C
Diastole
2C
Systole
LVESV = 120 ml
Assessing High Risk Features & Prognosis in DCM
Case 5 (male / 58 y, 2009)
2009.10
Heart Failure
2009.11
Heart Failure (f/u)
Assessing High Risk Features & Prognosis in DCM
Case 5 (male / 60 y, 2011)
• 2005)
14% 115 / 99 ml
• 2008)
29% 169 / 120 ml
• 2009)
28% 168 / 121 ml
• 2009)
23% 158 / 122 ml
• 2011)
17% 154 / 128 ml
Assessing High Risk Features & Prognosis in DCM
Case 6 (F / 72)
Assessing High Risk Features & Prognosis in DCM
Case 6 (F / 72), Contrast Echo
Assessing High Risk Features & Prognosis in DCM
LV diastolic dysfunction
Nagueh et al. JASE 2009;22:107
2008.7
2009.10 /29
aggravation
E = 48, A = 21
E = 51, A = 18
E = 43, A = 30
E = 57, A = 24
E/A = 2.3
E/A = 2.8
E/A = 1.4
E/A = 2.4
DT = 142
DT = 118
DT = 138
DT = 89
E’= 3.4
E’= 2.7
E’= 2.9
E’= 2.7
E/e’= 14.1
E/e’= 18.9
E/e’= 14.8
E/e’= 21.1
2009.11/3
2011.9/30
Assessing High Risk Features & Prognosis in DCM
RV dysfunction
• RV dysfunction may be present in DCM and is an
important adverse prognostic marker, associated with
significantly worse functional class and outcome
• TAPSE <14 mm is associated with an adverse prognosis
with DCM
Assessing High Risk Features & Prognosis in DCM
Tricuspid annular plane systolic excursion
(TAPSE)
RV
LV
TAPSE
RA
LA
Ghio. AJC
2000;85:837
Assessing High Risk Features & Prognosis in DCM
Mitral regurgitation
Secondary MR
apical tenting of the leaflet tips
annular dilatation
ventricular dyssynchrony
Case 7
Assessing High Risk Features & Prognosis in DCM
Stress echocardiography
• Stress echocardiography is a useful tool in guiding management in DCM, by
identifying the presence or absence of contractile reserve (improvement in wall
motion score, fractional shortening, or EF) during dobutamine infusion (10–40
mcg/kg/min).
• The presence of contractile reserve predicts a good response to therapies
(including drug treatment and MV repair), whereas absence of contractile
reserve predicts a poor survival rate. This has been used to guide management
decisions in the context of need for cardiac transplantation.
Case 8
Assessing High Risk Features & Prognosis in DCM
F / 52
Case 8
Assessing High Risk Features & Prognosis in DCM
Dobutamine echo
Assessing dyssynchrony in DCM
-guiding cardiac resynchronization therapy
• M-mode
• Doppler echo
• Tissue-Doppler imaging
• Tei index
SPWMD
septal-to-posterior wall motion delay
M-mode
Short – axis view
SPWMD 130 ms predicted a response to CRT
• Pitzalis MV et al. (Bari, Italy)
• JACC 2002;40:1615
• Heart failure : 20 pts (non-random)
• LVEVI & LVESVI - Remodeling
• Limited predicted value for CRT response
Poor feasibility
• Marcus et al. JACC 2005;46:2208
• Bleeker et al, AJC 2007;99:68
Doppler echo (pulsed wave Doppler)
Patients with severe DCM
- fusion of E – and A – waves
→ prolongation of total isovolumic time (t-IVT)
→ reduction in effective filling time (LVFT)
→ diastolic MR
Aortopulmonary preejection interval >40 ms
Doppler echo (MPI or Tei index)
role in selecting patients for CRT, but appear
most useful in assessing response to therapy
guiding therapeutic interventions
Measures of Ventricular Dyssynchrony
• QRS duration > 120 ms
• Increased aortopulmonary mechanical delay of >40 ms
• Increased septal posterior mechanical delay of >130 ms
• Increased time to peak velocity of opposing LV wall of >65 ms
• Increased time to peak negative strain of opposing LV walls
• Increased Yu index of >31 ms
• Segmental delay in radial strain
• Timing of endocardial excursion or regional EF by 3D echo
• Global LV strain by speckle tracking
Current Indications for CRT Device
• Systolic heart failure
• NYHA III or IV symptoms
• EF  35%
• QRS duration  120 msec
Cardiac Resynchronization Therapy (CRT)
Is echo useful in selecting patients for CRT?
• PROSPECT trial – did not support using echo
for selecting patients for CRT
Several methodological deficiencies
• poor training of the centers
• multiple vendors
• multiple core labs
• poor reproducibility of the measures
Benefits of CRT
• Reduction in LV size
• Improvement in EF
• Improved LV dP/dt
• Improvement in MR
• Improved exercise tolerance
• Reduced hospitalization
• Reduced mortality
Response Rate to CRT
about
70%
Conclusion (1)
Suspected heart failure or LV dysfunction
Echocardiography
LVEF < 45%
LVEDD >112%
LV size and
function
Conclusion (2)
(i) diagnosis of DCM or features of the ‘DCM phenotype’
(ii) identify associated cardiac abnormalities - valve
disease
(iii) highlight features requiring specific therapeutic Mx
(iv) identify high-risk features associated with an
adverse Px
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