Echocardiographic Features of

Dilated Cardiomyopathy
 Dilated cardiomyopathy
• Myocardial disorder sufficient to cause dilated LV (LVED >2.7 cm/m2 or
>117% and LVEF <45% in the absence of

1. Coronary artery disease

2. Valvular heart disease
3. Hypertension
4. Congenital heart disease

• The hallmark of the disease is a global LV dilation

Hypokinetic Non-Dilated cardiomyopathy
HNDC
• Myocardial disorders sufficient to cause LVEF <45% in and LV is non
dilated.
 Dilated cardiomyopathy

• Idiopathic cardiomyopathy
• Familial cardiomyopathy
• Noncompacted myocardium
• Peripartum cardiomyopathy
• Hemochromatosis
• Infectious
• Toxic cardiomyopathy
Primary diagnostic features of dilated
cardiomyopathy are left ventricular
dilation and systolic dysfunction.
Lv size
Left Side Chamber quantifications
Lv size-Linear
M-Mode Quantification
• Use Parasternal Short-Axis or Long-Axis views to measure LVEDD
and LVESD

• Measurement is taken perpendicular to the ventricle at the level of

tip of mitral leaflet

• Assumes that no significant regional wall motion abnormalities are

present
TEICHOLZ
SIMPSON’S METHOD
BIPLANE SIMPSONS

SIMPSON’S METHOD
SIMPSON’S METHOD

• In the presence of RWMA all the above methods will be less accurate, since inclusion of RWMA-
causes volume overestimation.

• The apical biplane methods are more robust in this setting, using summation of a series of disks
from apex to base (often called Simpson’s Rule).

• The ASE (American Society of Echocardiography) recommends use of biplane apical views with a
Simpson’s rule approach
 AREA - LENGTH METHOD

Base of ventricle = cylinder

Apex of ventricle = ellipsoid
Volume is calculated using a long axis length L and
cross-sectional area Am of an orthogonal short-axis
view at the mid-papillary muscle.
V = (Am) L/2 + 2/3 (Am) L/2
V = 5/6 AL (Bullet Formula)

VOLUME=5 (Area )(length)/6

Ischemic DCM
Assessment of LV systolic function
 B- notch
• Delayed closure of mitral leaflets
between the leaflet coaptation points,
determining a "notch" known as B-
bump

• Indicates increased left ventricular

end-diastolic pressure ( > 20mmhg)

• LIMITATIONS
• 1) Low sensitivity
• 2)false positive with first degree AV
block & LBBB-due to prolonged AC
interval

Ambrose J A et al Circulation60:510-519 1979

GRADUAL CLOSURE OF AORTIC VALVE

Decreased LV forward flow causes gradual reduction in forward flow in late systole

This results in rounded appearance of aortic valve closure in late systole

Fractional shortening
Ejection fraction
• Preload

• Afterload

• Contractility
 Global Myocardial Function
• Fractional shortening (FS)
– Assumes symmetric
contraction

• Ejection fraction (EF)

EF=EDV-ESV/EDV
Myocardial Performance Index
• Applied to either the left or right
ventricle.

• Ejection time (ET), isovolumic

contraction time (IVCT) and the
isovolumic relaxation time (IVRT).

• MPI = ( IVCT + IVRT ) / ET

Systolic dysfunction is associated with a prolongation of IVCT and a shortening of the ET

Normal range is 0.39 ± 0.05, and values > 0.50 are considered abnormal
RATE OF VENTRICULAR PRESSURE RISE (dp/
dt)
• When Mitral regurgitation is present the CW Doppler
velocity curve indicates the instantaneous pressure
difference between the left ventricle and left atrium

• The slope of the MR jet velocity can be quantitated as

the rate of change in pressure over time (dP/dt) by
measuring the time interval between the MR jet velocity
at 1 and 3 m/s
 What we need to know in DCM
• Am I missing a treatable cause ?

• Is my patient high risk category ?

• Is my treatment appropriate ?

• What is chance of recovering LVEF ?

• Will my patient benefit from CRT?

• Should I screen the family members ?

Prognostication in DCM

Phenotype ranges from patients who remain largely asymptomatic

to those who succumb to multiple hospital admissions and premature
death.

Taylor et al. Journel of cardiovascular magnetic Resonance(2016) 18:1

Prognostic markers in DCM
• GLS

• Functional MR

• Thrombus

• LA size and function

• Rv functions

• Cardiac MRI
Myocardial damage

Longitudinal fibers

Recovery

Circumferential fibers

Helical fibers
 Early myocardial damage

Reduced longitudinal contraction

Compensatory increased circumferential contraction
Increased twist
Reduction in LV size
Left ventricular hypertrophy

Ejection fraction is maintained

 More myocardial damage

Further reduction in longitudinal strain

Reduced circumferential contraction
Reduced Twist

Ejection fraction is reduced

Functional mitral regurgitation
Tenting distance 0.45 cm can predict
80% probability of being in mild FMR
and 2.35 cm can predict 80% probability
of being in severe FMR.
Thrombosis
Left atrium
Rv function
What is chance of recovering lVEF?

Recovery

HFrEF Remission

Deterioration
Circ heart fail.2017 june
Peripartum cardiomyopathy
Noncompaction of ventricular myocardium
(NVM)
Sarcoidosis
Predicting improvement after CRT

Septal flash and apical rocking

is a favourable prognostic sign
and is associated with
frequent improvement of LV
function
Thankyou
 DP/DT-Lv function assesment

d
t

1 m/s, 4
mmHg

d
P
3 m/s, 36
mmHg
 Evaluation of LV Systolic Function

At each velocity, the corresponding pressure gradient is 4v squared per

Bernoulli.

dP/dt = [ 4 (3) (3) – 4 (1) (1)] = 32 mmHg

Time interval Time interval

Thus a longer time interval indicates a depressed dP/dt and thus a

decreased LV systolic function.
• As LV becomes more spherical as it dilates the relation between
major and minor axis changes.

• Therefore a regression formula was devised to correct for this change

in shape

LVV=( 7.0/2.4+D) x Dcube

 TEICHOLZ /CUBED FORMULA

• LV Volume calculation is based on assumption that the LV is a prolate ellipse

LV VOLUME= 4/3 xPi x D1/2 x D1/2 x 2D1/2
= Pi/3 x D cube =1.047 x D cube = D cube

This structure has two minor axis D1 & D2 and

a major axis L

V=4/3 Pi X D1/2 X D2/2 X L/2

• Basic assumptions
• LV dilates along the minor axis
• LV internal diameter is equal to one of the minor axis of the ellipse D1
• Both minor axis of ellipse D1,D2 are equal
 Limitations:
• This method is only useful in patients with enough MR to obtain a well-defined velocity
curve.

• LA should be compliant.

• Click artifact (caused by valve closure) can obscure the descending limb of the CWD
envelope, which makes measurements difficult.

• Eccentric MR jets may not reflect true velocity and will result in underestimation of dp/dt
unless careful colour Doppler examination of the jet is made to minimize CWD error.

• A normal dp/dt maybe present in hypertension and aortic stenosis even with impaired LV
function.
• What is chance of recovering lVEF?
• Recovery
• Remission
• Deterioration