VOTW: In the Thick of It

HPI

A 40-year-old female with a PMH of polycystic kidney disease, HLD, and HTN presents with 1 month of episodic dizziness. She was referred to the ED by her cardiologist for an abnormal EKG, and had previously been told that she had an enlarged heart. 

Her vital signs are unremarkable. Physical exam is notable for a harsh, blowing systolic murmur. Chest X-ray shows cardiomegaly.

Ultrasound Findings

Point-of-care echocardiogram showed no pericardial effusion and was notable for septal thickening to 2.2 cm, concerning for hypertrophic obstructive cardiomyopathy (HOCM).

Echocardiography is the first-line imaging modality for the diagnosis of hypertrophic cardiomyopathy. 

Key findings are wall thickening and intraventricular obstruction. 

• Wall thickening > 15 mm (or > 13 mm in patients with relatives diagnosed with HOCM). This can be measured in the parasternal long or short axis views. 

• Interventricular septum to posterior wall thickness ratio of > 1.3 in normotensive patients or > 1.5 in patients with HTN

• Thickening usually occurs on a focal region of the LV wall

Other associated findings include mitral valve abnormalities, systolic dysfunction, and diastolic dysfunction.

• Systolic anterior motion of the mitral valve may occur in HOCM due to the Venturi effect. Septal hypertrophy narrows the LVOT, accelerating blood flow and creating a suction force that pulls the mitral valve leaflet into the LVOT. This causes outflow obstruction as well as mitral regurgitation. 

Case Conclusion

Based on these findings, the patient was placed in observation for cardiology evaluation. 

Comprehensive echocardiogram revealed findings consistent with HOCM, including severe asymmetric left ventricular hypertrophy, hyperdynamic LV systolic function (LVEF 76-80%), moderate (grade 2) LV diastolic dysfunction, LV outflow tract obstruction, moderate systolic anterior motion of the anterior leaflet of the mitral valve, and moderate mitral valve regurgitation.

The patient was newly diagnosed with and educated about HOCM. She was discharged with metoprolol 25 mg daily and is anticipated to undergo further treatment with mavacamten and possible septal reduction surgery. 

References & Further Reading

• https://coreultrasound.com/5-minute-sono-hcm-and-lvoto-2024/ 

• https://www.acep.org/emultrasound/newsroom/jan2023/motion-of-the-hocean-a-clinical-case-of-hypertrophic-obstructive-cardiomyopathy 

• https://pmc.ncbi.nlm.nih.gov/articles/PMC8423594/ 

• https://www.acc.org/Latest-in-Cardiology/Articles/2018/04/20/08/41/Imaging-in-Hypertrophic-Cardiomyopathy 

Happy scanning! 

VOTW: Love Trap - A Case of Takotsubo Cardiomyopathy

HPI

A 74-year-old female with a PMH of HTN, scoliosis, and stroke presents to the ED for worsening generalized weakness and poor appetite for 5 days. The patient is tachycardic, tachypneic, and hypoxic to 88%. Her most recent echocardiogram less than a year ago showed a LVEF of 51-55%.

Ultrasound Findings

Bedside echocardiogram showed abnormal wall motion, specifically apical ballooning of the left ventricle

The diagnosis of Takotsubo cardiomyopathy relies on two main criteria:

1) Transient left ventricular wall motion abnormality

2) The absence of a condition obviously explaining this wall motion abnormality

The classic pattern on ultrasound is akinesis of the apex accompanied by hypercontractility of the base, causing an appearance of systolic “ballooning” of the apex. This occurs in 80% of cases; however other variants exist.

Regional wall motion abnormalities extend beyond the distribution of any single coronary artery, sometimes helping differentiate this condition from MI.

Serial echos may show changes in these abnormalities over time.

LV outflow tract obstruction may complicate this condition, causing hemodynamic collapse.

Case Conclusion

ED workup revealed an elevated troponin and BNP, influenza B positive, and the patient was admitted given concern for myocarditis versus ACS.

A comprehensive echo was performed, showing a LVEF of 21-25% and findings consistent with Takotsubo cardiomyopathy. A CTA coronary scan was also performed, showing no evidence of significant CAD. The patient had a complicated hospital course but was medically optimized and ultimately discharged.

References

• https://emcrit.org/ibcc/takotsubo/#echocardiography

• https://www.aliem.com/takotsubo-cardiomyopathy-the-octopus-trap/

• https://radiopaedia.org/articles/takotsubo-cardiomyopathy?lang=us

• https://www.emdocs.net/em3am-takotsubo-cardiomyopathy/

VOTW: Regional Wall Motion Abnormality

This weeks VOTW is brought to you by Dr. Eng and Dr. Xu!

An 82 year old male presented to the ED w/ confusion, slurred speech and fall. A stroke alert was called initially, however the EKG obtained showed deep inverted T-waves in the anterior leads as well as ST-elevation in I and aVL. A POCUS was performed which showed…

Clip 1 shows a parasternal short axis view of the heart. The septum, posterior and inferior walls appear to be contracting appropriately but the anterior and lateral walls appear akinetic. Clip 2 shows an apical 4 chamber view of the heart where again the septum appears to be contracting well but the apex and lateral walls appear to be akinetic. The area of akinesis correlates with the ST-changes seen on the EKG.

SALPI

Regional Wall Motion Abnormality

To evaluate for a regional wall motion abnormality (RWMA) remember the acronym SALPI (image 1). In the parasternal short axis view, starting at the septum, go clockwise to identify the anterior – lateral – posterior – inferior walls. To look for a RWMA, look closely at each wall during systole to see if:

1. The myocardium is moving in towards the center of the ventricle

2. The myocardium is increasing in thickness

The absence of these findings is concerning for a RWMA which may be indicative of an acute MI. Patients with old MIs may also have RWMAs - correlate with the EKG and old echos if available

The parasternal long axis view and apical 4 chamber views can also be used to evaluated for RWMA (image 2).

When to POCUS for RWMA

This may be especially helpful in patients w/ equivocal EKGs that you or cardiology is on the fence about activating the cath lab or when the symptoms are not quite consistent with an MI (as in this case). Finding a RWMA may expedite cath lab activation (1).

Pro Tip: Cover up the entire LV with your hand except the specific wall you’re looking at and look at each wall seperately.

Back to the patient

The patient did not have any active chest pain but the initial troponin returned at 27.

The patient was taken to the cath lab which showed triple vessel disease with 80% stenosis of mid-LAD, 95% stenosis of first diagonal, 95% stenosis of proximal circumflex. He was evaluated for CABG but ultimately chose medical therapy.

References:

(1) Xu C, Melendez A, Nguyen T, Ellenberg J, Anand A, Delgado J, et al. Point-of-care ultrasound may expedite diagnosis and revascularization of occult occlusive myocardial infarction. Am J Emerg Med. 2022;58:186–91.