Faculty Bibliography
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Journal of the American Society of Echocardiography. 2015:28(12):1462-73.DOI: 10.1016/j.echo.2015.08.015
Doppler Systolic Signal Void in Hypertrophic Cardiomyopathy: Apical Aneurysm and Severe Obstruction without Elevated Intraventricular Velocities
BACKGROUND: In patients with hypertrophic cardiomyopathy (HCM), akinetic apical aneurysms are associated with ventricular tachycardia, heart failure, apical thrombus, and mortality. The cause of apical aneurysms remains unresolved, and there is controversy about prevalence and significance of mid-left ventricular (LV) obstruction, often present in these patients. The aim of this study was to test the hypothesis that low velocities in patients with aneurysms are due to near complete cessation of mid-LV flow, characteristically marked by a Doppler signal void. METHODS: This was a retrospective analysis of 39 patients with HCM with segmental hypertrophy of the mid left ventricle and complete systolic emptying at the mid-LV level. The severity of dynamic obstruction was evaluated by measuring the time during which cross-sectional mid-LV cavity area was <1 cm(2). Presence or absence of an LV Doppler midsystolic signal void was determined. RESULTS: Akinetic apical aneurysms were present in 21 patients. The duration of two-dimensional mid-LV short-axis complete emptying was longer in patients with akinetic apical aneurysms (194 +/- 45 vs 148 +/- 63 msec, P = .013), nearly 50% of systole. Midsystolic signal voids were seen only in patients with akinetic apical aneurysms (P < .001), present in 86%. In patients with akinetic aneurysms, there was a strong correlation between the duration of the systolic signal void and the proportion of systole with complete emptying <1 cm(2) (r = 0.704; P = .001). Complete emptying <1 cm(2) for >/=38% of systole was associated with akinetic aneurysm (odds ratio, 9.35; P < .004). CONCLUSION: Patients with akinetic apical aneurysm HCM have near complete cessation of flow across severe dynamic mid-LV obstruction for nearly 50% of systole. This explains how the adverse effects of obstruction may occur without high velocities on echocardiography.
PMID: 26422555
ISSN: 1097-6795
CID: 1906792
Journal of the American Society of Echocardiography. 2015:28(11):1318-28.DOI: 10.1016/j.echo.2015.07.002
Echocardiography before and after Resect-Plicate-Release Surgical Myectomy for Obstructive Hypertrophic Cardiomyopathy
BACKGROUND: Anatomic features of obstructive hypertrophic cardiomyopathy are septal hypertrophy, elongated mitral leaflets, and anterior displacement of the papillary muscles. In addition to extended myectomy, the resect-plicate-release operation adds horizontal plication of the anterior mitral leaflet (AML) and release of the anterolateral papillary muscle (APM) in selected patients. The aim of this study was to test the hypotheses that (1) preoperative findings would be associated with procedures applied, (2) anatomic corrections would be observable postoperatively, and (3) there would be consistently good physiologic outcomes. METHODS: A retrospective study was conducted of patients with obstructive hypertrophic cardiomyopathy who had adequate echocardiograms before and 9.5 +/- 12 months after the resect-plicate-release operation was performed from 2006 to 2012. RESULTS: Seventy-seven patients underwent myectomy, 50 AML plication, and 50 APM release. Patients who underwent plication had longer AMLs (32 +/- 4 vs 28 +/- 4 mm; P < .004). Anterior extension of the APM was more common with papillary muscle release (86% vs 62%, P < .04). Twenty-seven (35%) had septal thickness
PMID: 26272699
ISSN: 1097-6795
CID: 1745022
Reply: The Strain, the Valve, and the LVOT Obstruction [Letter]
PMID: 25953757
ISSN: 1558-3597
CID: 1570742
Journal of the American College of Cardiology. 2014:64(24):2601-2604.DOI: 10.1016/j.jacc.2014.10.007
Thin-filament mutations, hypertrophic cardiomyopathy, and risk [Comment]
PMID: 25524338
ISSN: 1558-3597
CID: 1570852
Vector flow mapping in obstructive hypertrophic cardiomyopathy to assess the relationship of early systolic left ventricular flow and the mitral valve
BACKGROUND: The hydrodynamic cause of systolic anterior motion of the mitral valve (SAM) is unresolved. OBJECTIVES: This study hypothesized that echocardiographic vector flow mapping, a new echocardiographic technique, would provide insights into the cause of early SAM in obstructive hypertrophic cardiomyopathy (HCM). METHODS: We analyzed the spatial relationship of left ventricular (LV) flow and the mitral valve leaflets (MVL) on 3-chamber vector flow mapping frames, and performed mitral valve measurements on 2-dimensional frames in patients with obstructive and nonobstructive HCM and in normal patients. RESULTS: We compared 82 patients (22 obstructive HCM, 23 nonobstructive HCM, and 37 normal) by measuring 164 LV pre- and post-SAM velocity vector flow maps, 82 maximum isovolumic vortices, and 328 2-dimensional frames. We observed color flow and velocity vector flow posterior to the MVL impacting them in the early systolic frames of 95% of obstructive HCM, 22% of nonobstructive HCM, and 11% of normal patients (p < 0.001). In both pre- and post-SAM frames, we measured a high angle of attack >60 degrees of local vector flow onto the posterior surface of the leaflets whether the flow was ejection (59%) or the early systolic isovolumic vortex (41%). Ricochet of vector flow, rebounding off the leaflet into the cul-de-sac, was noted in 82% of the obstructed HCM, 9% of nonobstructive HCM, and none (0%) of the control patients (p < 0.001). Flow velocities in the LV outflow tract on the pre-SAM frame 1 and 2 mm from the tip of the anterior leaflet were low: 39 and 43 cm/s, respectively. CONCLUSIONS: Early systolic flow impacts the posterior surfaces of protruding MVL initiating SAM in obstructive HCM.
PMID: 25440093
ISSN: 1558-3597
CID: 1570762
Apical Akinetic Chambers Occur in Hypertrophic Cardiomyopathy Patients With the Most Severe Mid Left Ventricular Obstruction but Low or Absent Systolic Pressure Gradients [Meeting Abstract]
ISI:000332162903392
ISSN: 0009-7322
CID: 2955772
Journal of the American College of Cardiology. 2013:61(24):2487-2488.DOI: 10.1016/j.jacc.2013.02.079
Post-prandial upright exercise echocardiography in hypertrophic cardiomyopathy [Letter]
PMID: 23602772
ISSN: 1558-3597
CID: 1570872
A primer of disopyramide treatment of obstructive hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy (HCM) occurs in 1 in 500 individuals. Treatment options for HCM differ from those administered in coronary disease, heart failure, and valvular disease patients that comprise the core of many cardiology practices. In this article, we offer a concise summary of the therapeutic use of disopyramide for reducing gradients and relieving symptoms in obstructive HCM.
PMID: 22687589
ISSN: 1873-1740
CID: 1570932
Echocardiography to individualize treatment for hypertrophic cardiomyopathy
Treatments for hypertrophic cardiomyopathy are largely selected based on patient symptoms and echocardiographic findings. Moreover, all the advanced treatments for heart failure symptoms depend on such imaging for planning and monitoring response to therapy. Risk of sudden death correlates with maximum left ventricular (LV) wall thickness. Massive LV thickening of 30 mm or more is an indication for primary prevention of sudden death with an implanted defibrillator. In this review, we will underscore potential pitfalls in echocardiographic diagnosis. Also we will review, a newly appreciated pathophysiologic mechanism in obstruction dynamic systolic dysfunction due to gradient.
PMID: 22687587
ISSN: 1873-1740
CID: 1570942
POST-PRANDIAL UPRIGHT EXERCISE STRESS ECHOCARDIOGRAPHY IN OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY [Meeting Abstract]
ISI:000302326701047
ISSN: 0735-1097
CID: 2955762
