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Echocardiographic diagnosis of mitral regurgitation in congestive cardiomyopathy
Echocardiographic diagnosis of mitral regurgitation in congestive cardiomyopathy Jorge A. Levisman, M.D. Los Angeles, Calif.
Echocardiography has made a valuable contribution to the understanding of congestive, hypertrophic, and infiltrative cardiomyopathies. 1-11The echocardiographic findings which have been described in congestive cardiomyopathy are: a dilated left ventricular cavity, poor interventricular septal and posterior wall motion, and normal wall thickness. 1-3 Normal or increased septal motion in the dilated left ventricle with poor posterior wall motion has been interpreted as evidence for segmental myocardial disease, namely, focal myocardial damage with intact septal function, which would exclude congestive cardiomyopathy. 4 We have studied eight patients with congestive cardiomyopathy diagnosed by cardiac catheterization who had an apparently normal or increased septal motion on the echocardiogram. This pattern correlated with the presence of significant mitral regurgitation. Patient selection and methods
Eighteen patients presenting with congestive heart failure were diagnosed as having congestive cardiomyopathy on the basis of clinical evaluation, cardiac catheterization, and angiocardiography. Patients with obstructive coronary disease, aortic valve disease, prosthetic valves, or mitral stenosis were excluded. Two independent observers evaluated the left ventriculograms for mitral regurgitation and grouped the studies into four categories: (1) no regurgitation; (2) mild, small amount of regurgiFrom the Department of Medicine, Division of Cardiology, University of California School of Medicine, Los Angeles, Calif. This work was supported in part by Grant 490-1G1 from the American Heart Association-Greater Los Angeles Affiliate. Received for publication Sept. 23, 1975. Reprint requests: Jorge A. Levisman, M.D., Department of Medicine, UCLA Center for the Health Sciences, Los Angeles, Calif. 90024.
January, 1977, Vol. 93, No. 1, pp. 33-39
tant contrast but not enough to delineate the left atrium; (3) moderate, clear visualization of the left atrium but never reaching the density of the left ventricle; and (4) severe, the left atrium became as densely opacified as the left ventricle. Both observers agreed with each other on all studies except one t h a t was interpreted as moderate by one and severe by the other. Echocardiograms were performed with an Ekoline 20 echocardiograph machine utilizing a 10 cm. focus transducer at 2,25 MHz with a repetition rate of 1,000 per second. The tracings were recorded on a Honeywell 1856 recorder. From the tracings the following measurements were made. 1. Left ventricular end-diastolic diameter (Dd): The distance between the left septal surface and the endocardium of the posterior wall below the mitral valve, at the R wave of the ECG {normal less than 5.4 cm.). 2. Left ventricular end-systolic diameter (Sd): The shortest simultaneous distance between septal and posterior wall endocardium in systole. 3. Left atrial size in systole (maximum inner diameter normally less than 3.8 cm). 4. Mitral valve diastolic (E-F) slope {normal 60 to 150 mm. per second). 5. Aortomitral discontinuity (AMd): The anteroposterior distance between the systolic closure of the mitral valve (C point) and the posterior wall of the aortic root at the beginning of systole {normal less than 8 mm.) ~~ (see Fig. 1). 6. Left ventricular posterior wall thickness in diastole prior to the "a'" dip {normal 0.7 to 1.1 cm.). 7. Left ventricular posterior wall motion: The excursion of the posterior endocardium from
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Levisman
Fig. 1. Normal echocardiogram. A, Aortic root; C, mitral closure point; ECG, electrocardiogram; LV, left ventricle; LA, left atrium; MV, mitral valve; Post LV, posterior left ventricular wall. The dashed line indicates the levels of the mitral closure and the posterior aortic wall for determination of aortomitral discontinuity (AMd). In this patient the AMd measures 4 mm.
Fig. 2. Normal echocardiogram. The dark lines across the septum indicate the systolic and diastolic septal thickness. The systolic thickening is 50 per cent. Abbreviations as in Fig. 1.
t h e diastolic p o s i t i o n at t h e p e a k of t h e R w a v e to its m o s t a n t e r i o r p o s i t i o n in s y s t o l e ( n o r m a l 1.0 to 1.4 cm.).
8. Septal diastolic thickness (DTH) prior to the "'a'" dip ( n o r m a l 0.8 to 1.2 cm.). 9. Septal systolic thickening (STHg)4: T h e per c e n t c h a n g e of s e p t a l t h i c k n e s s s y s t o l e w i t h t h e use of t h e f o r m u l a STHg =
STH - DTH DTH
•
during
100
W h e r e S T H is t h e m a x i m u m systolic thick-
34
ness of t h e s e p t u m (Fig. 2). S e p t a l systolic t h i c k e n i n g w a s also m e a s u r e d on t h e echoc a r d i o g r a m s of (1) 20 n o r m a l subjects, (2) e i g h t p a t i e n t s w i t h left v e n t r i c u l a r v o l u m e o v e r l o a d d u e to aortic or m i t r a l r e g u r g i t a t i o n a n d n o r m a l coronaries, a n d (3) five p a t i e n t s w i t h c o r o n a r y disease a n d segmental akinesis or dyskinesis o n t h e v e n t r i c u l o gram, n o r m a l left a n t e r i o r descending c o r o n a r y a r t e r y , a n d no v a l v u l a r r e g u r g i t a t i o n . 10. Septal motion: T h e e x c u r s i o n of t h e left septal e n d o c a r d i u m f r o m e n d diastole at t h e
January, 1977, Vol. 93, No, 1
Echocardiographic diagnosis of mitral regurgitalion Table I. Echocardiographic measurements on 18 patients with congestive cardiomyopathy*
L. V. cavity L.A,
Mx.
Dd. I Sd. (cm.) (cm.) Normal 1. P.H. 2. R.G. 3. A.G. 4. L.E. 5. F.B. 6. J.A. 7. M.M. 8. W.S. 9. M.M. 10. G.B. 11. P.W. 12. Ch. M. 13. G.B. 14. Ch. R. 15. Ch. O. 16. B. R. 17. R.G. 18. B.S. Mean _+ S.E.
4.0-5.4 7.0 8.0 8.0 6.5 6.6 7.4 7.2 7:6 5.8 6.2 7.4 7.2 6.0 8.0 7.5 8.5 7.0 7.8 7.2 _+ 0.17
(cm.) <
6.4 6.8 7.0 5.8 5.2 6.2 5.8 6.8 5.4 5.4 6.9 6.5 4.7 7.5 6.8 7.0 6.1 6.0 6.2 _+ 0.17
M. V. E-F. slope (mm./sec.)
3.8 4.0 4.0 3.6 5.4 4.2 3.8 3.9 4.6 5.0 4.2 4.6 4.3 3.8 4.2 4.1
4.O 5.0 4.3 + 0.12
60-150 80 170 160 80 80 100 74 120 100 90 82 150 90 87 100 120 95 120 105 _+ 6.8
AMd (mm.) < 8 30 20 15 14 18 20 10 20 12 14 17 15 16 14 18 14 14 16.5 _+ 1.1
L VPW
L V. septum
DTH I M (cm.) (cm.
DTH I STHg ] M (cm.) (%) (cm.)
0 . 7 - 1 . 1 1.0-1.4 0.8-1.2 1.0 0.9 1.1 0.7 0.6 0.8 1.0 0.9 0.9 0.8 0.5 0.9 0.7 0.8 0.6 0:8 0.7 0.8 0.8 0.6 0.9 0.8 0.8 0.8 0.7 0.8 0.8 1.0 0.8 1.0 0.8 0.5 0.9 0.8 0.8 0.9 0.8 0.9 0.9 1.0 0,7 1.1 0.9 0.8 1.0 0.8 0.8 0.8 0.8 0.9 0.8 0.9 0.9 1.0 0.8 0.76 0.88 _+ 0.02 + 0.03 _+ 0.03 +
30 10 0 0 0 0 0 0 0 0 0 0 0 20 0 10 10 0 20 3.94 1.60
0.4-0.7 0.1 0.8 0 0.5 0.6 0.7 0 0 0.2 0 0.4 0 0.2 0 0.3 1.2 0.4 0.8 0.35 _ 0.08
Angiogram Mo Mo Mo Mo Se Mo None None Mo Mi Se Mi Mi Mo Mi Mo Mo Mo
*Abbreviations:L.V. cavity,left ventricularcavity;Dd, diastolicdiameter; Sd, systolicdiameter;LA, left atrium; MV, mitral valve;AMd,aortomitral discontinuity;LVPW,left ventricularposteriorwall; TH, thickness;M, motion;IV septum,iaterventricularseptum; DTH,diastolicthickness;STHg, systolic thickening;Mi, mild; Mo, moderate; Se, severe. p e a k of t h e R w a v e of t h e E C G to its m o s t p o s t e r i o r p o i n t i n s y s t o l e ( n o r m a l 0.4 t o 0.7 cm.).
11. Passive septal -(STH-DTH).
motion = septal
motion
Results T h e e c h o c a r d i o g r a p h i c m e a s u r e m e n t s o n t h e 18 p a t i e n t s w i t h c o n g e s t i v e c a r d i o m y o p a t h y are s h o w n i n T a b l e I. T h e y r e v e a l d i l a t a t i o n of t h e left v e n t r i c l e ( D d 7.2 _+ 0.17 cm.) a n d left a t r i u m ( m a x i m u m d i a m e t e r 4 . 3 _ 0.12 cm.). I n o n e p a t i e n t t h e left a t r i a l e c h o g r a m c o u l d n o t be e v a l u a t e d . T h e m i t r a l v a l v e d i a s t o l i c ( E - F ) slope was u s u a l l y n o r m a l (105 ___ 6.8 m m . p e r second). A o r t o m i t r a l d i s c o n t i n u i t y was i n c r e a s e d i n all 17 p a t i e n t s i n w h o m it c o u l d be e v a l u a t e d (16.5 +_ 1.1 m m . ) . L e f t v e n t r i c u l a r p o s t e r i o r w a l l m o t i o n w a s d e c r e a s e d i n all p a t i e n t s (0.76 _+ 0.03 cm.) w i t h n o r m a l p o s t e r i o r w a l l t h i c k n e s s (0.8 _ 0.22 cm.). I n t e r v e n t r i c u l a r s e p t a l t h i c k n e s s was n o r m a l i n a l l 18 p a t i e n t s (0.88 +_ 0.03 cm.). S y s t o l i c t h i c k e n i n g of t h e s e p t u m was a b s e n t i n 13 p a t i e n t s a n d w a s r e d u c e d i n all o t h e r s (3.94 _ 1.60 p e r c e n t ) .
American Heart Journal
S e p t a l m o t i o n w a s a b s e n t or d e c r e a s e d i n 10 p a t i e n t s (Fig. 3), six of w h o m h a d m i l d or n o m i t r a l r e g u r g i t a t i o n . T w o of t h e s e p a t i e n t s h a d left b u n d l e b r a n c h block. F o u r h a d m o d e r a t e m i t r a l regurgitation on the angiogram. Eight p a t i e n t s h a d n o r m a l or i n c r e a s e d s e p t a l m o t i o n (Fig. 4) a n d all of t h e s e p a t i e n t s h a d s i g n i f i c a n t m i t r a l r e g u r g i t a t i o n o n a n g i o g r a p h y (Fig 5). C o r r e c t i o n of s e p t a l m o t i o n for t h i c k e n i n g (passive s e p t a l m o t i o n ) did n o t s i g n i f i c a n t l y c h a n g e the results. S e p t a l s y s t o l i c t h i c k e n i n g w a s 50 +_ 2.41 p e r c e n t ( S . E . M . ) ( r a n g e 30 to 70 p e r c e n t ) i n o u r 20 n o r m a l s u b j e c t s , 73 ___ 2.78 p e r c e n t ( r a n g e 60 t o 86 per c e n t ) i n t h e e i g h t p a t i e n t s w i t h left v e n t r i c u l a r v o l u m e o v e r l o a d , a n d 7 0 _ 7.61 per c e n t ( r a n g e 58 t o 100 p e r c e n t ) i n t h e five p a t i e n t s w i t h c o r o n a r y disease a n d n o r m a l s e p t a .
Discussion I n t h e s e 18 p a t i e n t s w i t h c o n g e s t i v e c a r d i o m y o p a t h y t h r e e f e a t u r e s were c o n s t a n t i n t h e echoc a r d i o g r a m of t h e left v e n t r i c l e , n a m e l y , a d i l a t e d cavity, reduced posterior wall motion, a n d d e c r e a s e d s e p t a l s y s t o l i c t h i c k e n i n g ( T a b l e I). i n
35
Levisman
Fig. 3. Echocardiogram of a patient with congestive cardiomyopathy without mitral regurgitation (Case 12, Table I). Note the absence of both septal motion and systolic thickening. There is also biventricular dilatation. Abbreviations as in Fig. 1.
Fig. 4. Echocardiogram of a patient with congestive cardiomyopathy and severe mitral regurgitation (Case 6, Table I). Note the apparent normal septal motion and no systolic thickening as indicated by the dark lines. 10 p a t i e n t s septal m o t i o n was reduced or a b s e n t as previously reported. In the o t h e r eight p a t i e n t s septal m o t i o n was either " n o r m a l " or increased; however, an a p p a r e n t n o r m a l septal m o t i o n w i t h o u t systolic thickening suggests a passive m o t i o n t h a t is n o t due to c o n t r a c t i o n of the m y o c a r d i u m . I n these eight p a t i e n t s there was significant m i t r a l regurgitation. This v o l u m e
36
overload of the left ventricle m a y m a k e the s e p t u m m o v e passively t o w a r d the right ventricle in diastole during v e n t r i c u l a r filling a n d posteriorly again as the v e n t r i c u l a r v o l u m e decreases in systole. A similar p a t t e r n of septal m o t i o n in congestive c a r d i o m y o p a t h y would p r o b a b l y also be p r o d u c e d b y left v e n t r i c u l a r v o l u m e overload due to a variety of causes.
January, 1977, Vol. 93, No. 1
Echocardiographic diagnosis of mitral regurgitation Four patients with significant mitral regurgitation showed decreased or absent septal motion and there were no detectable echocardiographic findings to suggest mitral regurgitation in these patients. On the other hand, no patient in this series showed apparently normal or increased septal motion in the absence of significant mitral regurgitation. The abnormal pattern of septal motion associated with left bundle branch block 13-15was not seen in the two patients with this conduction defect since contraction of the septum was not detectable. Analysis of septal motion by itself could not distinguish congestive cardiomyopathy with significant mitral regurgitation and passive septal motion from a dilated left ventricle d u e to myocardial infarction with a compensatory increase in septal motion. However, in the former condition there was reduced septal systolic thickening whereas the latter showed increased septal systolic thickening (Fig. 6), Volume overload of the left ventricle with normal or hypertrophied myocardium would also increase septal systolic thickening (Fig. 7). Reduced septal systolic thickening has been observed in hypertrophic cardiomyopathy.11 In this entity asymmetric hypertrophy of the septum and normal or small LV cavity size permit little difficulty in differential diagnosis. Reduced septal thickening is also a feature of infiltrative cardiomyopathy such as t h a t due to amyloid. TM Increased septal and posterior wall thickness and a small left ventricular cavity in this syndrome make it easily recognizable. An abnormal aortomitral "discontinuity" has been proposed as indirect evidence for mitral regurgitation? 2 We found an abnormally increased value in the 17 patients with congestive cardiomyopathy in whom it could be measured regardless of mitral valve competence, and it is probably related merely to dilatation of the left ventricle and to transducer position on the chest wall. Our study does not support previous observations of abnormal systolic motion of the mitral valve as evidence of mitral insufficiency in congestive cardiomyopathy.16 These observations confirm previous studies on congestive cardiomyopathy which have shown that a dilated left ventricle with normal wall thickness and reduced septal and posterior wall motion are the major echocardiographic features
American Heart Journal
1.2-
9
1.0--
.-g u
O0
0.8-
Z
o ~o .._]
<
0.60.4-
I-0._ I..d
u~
0.20.1O0
I
NONE
O0 I
O0 I
I
MILD MODERATE SEVERE
MITRAL REGURGITATION (ANGIOGRAPHY) Fig,
5.
Diagram showing the correlation between septal
motion and degreeof mitral regurgitation.The verticaldashed line separates the cases with no or mild regurgitation from moderate and severe. The horizontaldashed line is drawnjust below the lower limit of normal septal motion.
of this syndrome. We further suggest that an apparently normal or increased septal motion with reduced or no septal systolic thickening is also compatible with congestive cardiomyopathy and when present is evidence for coexistent left ventricular volume overload usually due to significant mitral regurgitation. Reduced or absent septal systolic thickening distinguishes this syndrome from segmental myocardial disease with intact septal function.
Summary Eighteen patients with congestive cardiomyopathy were studied by echocardiography and cardiac catheterization. Patients with coronary disease on angiography or primary valvular disease were excluded. Six patients showed mild or no mitral regurgitation; in 12 others the degree of mitral regurgitation was moderate or severe. The echocardiographic features in these patients were: (1) a dilated left ventricle (LV), (2) normal LV wall thickness, (3) reduced LV posterior wall motion, and (4) reduced or absent systolic thickening of the interventricular septum
(IVS). IVS motion was reduced in 10 patients, and
37
Levisman
Fig. 6. Echocardiogram of a patient with a posterior myocardial infarction. Septal systolic thickening is 100 per cent as indicated by the dark lines. The posterior wall motion is reduced.
Fig. 7. Echocardiogram of a patient with combined aortic sten0sis and insufficiency. The septal systolic thickening is 75 per cent, Note the concentric hypertrophy of the left ventricle, dilated left ventricular cavity, and prominent atrial deflection in the septum. a p p e a r e d " n o r m a l " o r i n c r e a s e d in a n o t h e r e i g h t , all of whom showed moderate or severe mitral regurgitation on angiography. I t is c o n c l u d e d t h a t a n a p p a r e n t n o r m a l o r increased motion of the IVS with reduced or a b s e n t s y s t o l i c t h i c k e n i n g in c o n g e s t i v e c a r d i o 38
m y o p a t h y i s e v i d e n c e f o r c o e x i s t e n c e o f significant mitral regurgitation. = Reduced or absent systolic thickening can distinguish these patients from those with segmental myocardial disease and normal septa or dilated LV's due to volume overload.
January, 1977, Vol. 93, No. 1
Echocardiographic diagnosis of mitral regurgitation The author wishes to thank Drs. Rex N. MacAlpin and Abdul S. Abbasi for their advice and encouragement, Drs. Cornelius J. Bos and Bruce M. Barack for reviewing the angiograms, Mrs, Nancy Ellis for technical assistance, and Mrs. Rita Bachtold and Mrs. Pat Ritter for the secretarial support. REFERENCES
1. Abbasi; A. S., Chahine, R. A., MacAlpin, R. N., and Kattus, A. A.: Left ventricular function in congestive cardiomyopathy, Chest 62:357, 1972. 2. Abbasi, A. S., Chahine, R. A., MacAlpin, R. N., and Kattus A. A.: Ultrasound in the diagnosis of primary congestive cardiomyopathy, Chest 63:937, 1973. 3. Corya, B. C., Feigenbaum, H., Rasmussen, S., and Black, M. J.: Echocardiographic features of congestive cardiomyopathy compared with normal subjects and patients with coronary disease, Circulation 49:1153, 1974. 4. Assad-Morell, J. L,, Tajik, A. J., and Giuliani, R. R.: Echocardiographic analysis of the ventricular septum, Prog. Cardiovasc. Dis. 17:219, 1974. 5. Abbasi, A. S., MacAlpin, R. N., Eber, L. M., and Pearce, M. L.: Echocardiographic diagnosis of idiopathic hypertrophic cardiomyopathy without outflow tract obstruction, Circulation 46"897, 1972. 6. Abbasi, A. S., MacAlpin, R. N., Eber, L. M., and Pearce, M. L.: Left ventricular hypertrophy diagnosed by echocardiography, N. Engl. J. Med. 289:118, 1973. 7. Henry, W. L., Clark, C. E., and Epstein, S. E.: Asymmetric septal hypertrophy (ASH). Echocardiographic identification of the pathognomonic anatomic abnormality of I.H.S.S., Circulation 47:225, 1973.
American Heart Journal
8. Tajik, A. J., and Giuliani, R. R.: Echocardiographic observations in idiopathic hypertrophic subaortic stenosis, Mayo Clin. Proc. 49:89, 1974. 9. Abbasi, A. S., Ellis, M., and Child, J. C.: Echocardiographic features of infiltrative cardiomyopathy, J. Clin. Ultrasound 2:221, 1974. 10. Levisman, J. A., Child, J. C., Abbasi, A. S, and MacAlpin, R. N.: Echocardiographic findings in amyloid heart disease, Circulation (abstr.) 52:II-208, 1975. 11. Rossen, R. M., Goodman, D. J., Ingham, R. E., and Popp, R. L.: Ventricular systolic septal thickening and excursion in idiopathic hypertrophic subaortic stenosis, N. Engl. J. Med. 291:1317, 1974. 12. Johnson, M. L., Kisslo, J., Warren, S. G., and Behar, V. S.: Echocardiographic diagnosis of mitral apparatus dysfunction with mitral insufficiency, J. Clin. Ultrasound 2:237, 1974. 13. Dillon, J. C., Chang, S., and Feigenbaum, H.: Echocardiographic manifestations of left bundle branch block (abst.), Circulation 48 (Suppl. IV)IV-126, 1973. 14. McDonald, I. G.: Echocardiographic demonstration of abnormal motion of the interventricular septum in left bundle branch block, Circulation 48:272, 1973. 15. Abbasi, A. S., Eber, L. M., MacAlpin, R. N., and Kattus, A. A.: Paradoxical motion of the interventricular septum in left bundle branch block, Circulation 49:423, 1974. 16. Wilward, D. K., McLaurin, L. P., and Craige, E.: Echocardiographic studies of the mitral valve in patients with congestive cardiomyopathy and mitral regurgitation, AM. HEART J. 85:413, 1973.
39
Echocardiography has made a valuable contribution to the understanding of congestive, hypertrophic, and infiltrative cardiomyopathies. 1-11The echocardiographic findings which have been described in congestive cardiomyopathy are: a dilated left ventricular cavity, poor interventricular septal and posterior wall motion, and normal wall thickness. 1-3 Normal or increased septal motion in the dilated left ventricle with poor posterior wall motion has been interpreted as evidence for segmental myocardial disease, namely, focal myocardial damage with intact septal function, which would exclude congestive cardiomyopathy. 4 We have studied eight patients with congestive cardiomyopathy diagnosed by cardiac catheterization who had an apparently normal or increased septal motion on the echocardiogram. This pattern correlated with the presence of significant mitral regurgitation. Patient selection and methods
Eighteen patients presenting with congestive heart failure were diagnosed as having congestive cardiomyopathy on the basis of clinical evaluation, cardiac catheterization, and angiocardiography. Patients with obstructive coronary disease, aortic valve disease, prosthetic valves, or mitral stenosis were excluded. Two independent observers evaluated the left ventriculograms for mitral regurgitation and grouped the studies into four categories: (1) no regurgitation; (2) mild, small amount of regurgiFrom the Department of Medicine, Division of Cardiology, University of California School of Medicine, Los Angeles, Calif. This work was supported in part by Grant 490-1G1 from the American Heart Association-Greater Los Angeles Affiliate. Received for publication Sept. 23, 1975. Reprint requests: Jorge A. Levisman, M.D., Department of Medicine, UCLA Center for the Health Sciences, Los Angeles, Calif. 90024.
January, 1977, Vol. 93, No. 1, pp. 33-39
tant contrast but not enough to delineate the left atrium; (3) moderate, clear visualization of the left atrium but never reaching the density of the left ventricle; and (4) severe, the left atrium became as densely opacified as the left ventricle. Both observers agreed with each other on all studies except one t h a t was interpreted as moderate by one and severe by the other. Echocardiograms were performed with an Ekoline 20 echocardiograph machine utilizing a 10 cm. focus transducer at 2,25 MHz with a repetition rate of 1,000 per second. The tracings were recorded on a Honeywell 1856 recorder. From the tracings the following measurements were made. 1. Left ventricular end-diastolic diameter (Dd): The distance between the left septal surface and the endocardium of the posterior wall below the mitral valve, at the R wave of the ECG {normal less than 5.4 cm.). 2. Left ventricular end-systolic diameter (Sd): The shortest simultaneous distance between septal and posterior wall endocardium in systole. 3. Left atrial size in systole (maximum inner diameter normally less than 3.8 cm). 4. Mitral valve diastolic (E-F) slope {normal 60 to 150 mm. per second). 5. Aortomitral discontinuity (AMd): The anteroposterior distance between the systolic closure of the mitral valve (C point) and the posterior wall of the aortic root at the beginning of systole {normal less than 8 mm.) ~~ (see Fig. 1). 6. Left ventricular posterior wall thickness in diastole prior to the "a'" dip {normal 0.7 to 1.1 cm.). 7. Left ventricular posterior wall motion: The excursion of the posterior endocardium from
American Heart Journal
33
Levisman
Fig. 1. Normal echocardiogram. A, Aortic root; C, mitral closure point; ECG, electrocardiogram; LV, left ventricle; LA, left atrium; MV, mitral valve; Post LV, posterior left ventricular wall. The dashed line indicates the levels of the mitral closure and the posterior aortic wall for determination of aortomitral discontinuity (AMd). In this patient the AMd measures 4 mm.
Fig. 2. Normal echocardiogram. The dark lines across the septum indicate the systolic and diastolic septal thickness. The systolic thickening is 50 per cent. Abbreviations as in Fig. 1.
t h e diastolic p o s i t i o n at t h e p e a k of t h e R w a v e to its m o s t a n t e r i o r p o s i t i o n in s y s t o l e ( n o r m a l 1.0 to 1.4 cm.).
8. Septal diastolic thickness (DTH) prior to the "'a'" dip ( n o r m a l 0.8 to 1.2 cm.). 9. Septal systolic thickening (STHg)4: T h e per c e n t c h a n g e of s e p t a l t h i c k n e s s s y s t o l e w i t h t h e use of t h e f o r m u l a STHg =
STH - DTH DTH
•
during
100
W h e r e S T H is t h e m a x i m u m systolic thick-
34
ness of t h e s e p t u m (Fig. 2). S e p t a l systolic t h i c k e n i n g w a s also m e a s u r e d on t h e echoc a r d i o g r a m s of (1) 20 n o r m a l subjects, (2) e i g h t p a t i e n t s w i t h left v e n t r i c u l a r v o l u m e o v e r l o a d d u e to aortic or m i t r a l r e g u r g i t a t i o n a n d n o r m a l coronaries, a n d (3) five p a t i e n t s w i t h c o r o n a r y disease a n d segmental akinesis or dyskinesis o n t h e v e n t r i c u l o gram, n o r m a l left a n t e r i o r descending c o r o n a r y a r t e r y , a n d no v a l v u l a r r e g u r g i t a t i o n . 10. Septal motion: T h e e x c u r s i o n of t h e left septal e n d o c a r d i u m f r o m e n d diastole at t h e
January, 1977, Vol. 93, No, 1
Echocardiographic diagnosis of mitral regurgitalion Table I. Echocardiographic measurements on 18 patients with congestive cardiomyopathy*
L. V. cavity L.A,
Mx.
Dd. I Sd. (cm.) (cm.) Normal 1. P.H. 2. R.G. 3. A.G. 4. L.E. 5. F.B. 6. J.A. 7. M.M. 8. W.S. 9. M.M. 10. G.B. 11. P.W. 12. Ch. M. 13. G.B. 14. Ch. R. 15. Ch. O. 16. B. R. 17. R.G. 18. B.S. Mean _+ S.E.
4.0-5.4 7.0 8.0 8.0 6.5 6.6 7.4 7.2 7:6 5.8 6.2 7.4 7.2 6.0 8.0 7.5 8.5 7.0 7.8 7.2 _+ 0.17
(cm.) <
6.4 6.8 7.0 5.8 5.2 6.2 5.8 6.8 5.4 5.4 6.9 6.5 4.7 7.5 6.8 7.0 6.1 6.0 6.2 _+ 0.17
M. V. E-F. slope (mm./sec.)
3.8 4.0 4.0 3.6 5.4 4.2 3.8 3.9 4.6 5.0 4.2 4.6 4.3 3.8 4.2 4.1
4.O 5.0 4.3 + 0.12
60-150 80 170 160 80 80 100 74 120 100 90 82 150 90 87 100 120 95 120 105 _+ 6.8
AMd (mm.) < 8 30 20 15 14 18 20 10 20 12 14 17 15 16 14 18 14 14 16.5 _+ 1.1
L VPW
L V. septum
DTH I M (cm.) (cm.
DTH I STHg ] M (cm.) (%) (cm.)
0 . 7 - 1 . 1 1.0-1.4 0.8-1.2 1.0 0.9 1.1 0.7 0.6 0.8 1.0 0.9 0.9 0.8 0.5 0.9 0.7 0.8 0.6 0:8 0.7 0.8 0.8 0.6 0.9 0.8 0.8 0.8 0.7 0.8 0.8 1.0 0.8 1.0 0.8 0.5 0.9 0.8 0.8 0.9 0.8 0.9 0.9 1.0 0,7 1.1 0.9 0.8 1.0 0.8 0.8 0.8 0.8 0.9 0.8 0.9 0.9 1.0 0.8 0.76 0.88 _+ 0.02 + 0.03 _+ 0.03 +
30 10 0 0 0 0 0 0 0 0 0 0 0 20 0 10 10 0 20 3.94 1.60
0.4-0.7 0.1 0.8 0 0.5 0.6 0.7 0 0 0.2 0 0.4 0 0.2 0 0.3 1.2 0.4 0.8 0.35 _ 0.08
Angiogram Mo Mo Mo Mo Se Mo None None Mo Mi Se Mi Mi Mo Mi Mo Mo Mo
*Abbreviations:L.V. cavity,left ventricularcavity;Dd, diastolicdiameter; Sd, systolicdiameter;LA, left atrium; MV, mitral valve;AMd,aortomitral discontinuity;LVPW,left ventricularposteriorwall; TH, thickness;M, motion;IV septum,iaterventricularseptum; DTH,diastolicthickness;STHg, systolic thickening;Mi, mild; Mo, moderate; Se, severe. p e a k of t h e R w a v e of t h e E C G to its m o s t p o s t e r i o r p o i n t i n s y s t o l e ( n o r m a l 0.4 t o 0.7 cm.).
11. Passive septal -(STH-DTH).
motion = septal
motion
Results T h e e c h o c a r d i o g r a p h i c m e a s u r e m e n t s o n t h e 18 p a t i e n t s w i t h c o n g e s t i v e c a r d i o m y o p a t h y are s h o w n i n T a b l e I. T h e y r e v e a l d i l a t a t i o n of t h e left v e n t r i c l e ( D d 7.2 _+ 0.17 cm.) a n d left a t r i u m ( m a x i m u m d i a m e t e r 4 . 3 _ 0.12 cm.). I n o n e p a t i e n t t h e left a t r i a l e c h o g r a m c o u l d n o t be e v a l u a t e d . T h e m i t r a l v a l v e d i a s t o l i c ( E - F ) slope was u s u a l l y n o r m a l (105 ___ 6.8 m m . p e r second). A o r t o m i t r a l d i s c o n t i n u i t y was i n c r e a s e d i n all 17 p a t i e n t s i n w h o m it c o u l d be e v a l u a t e d (16.5 +_ 1.1 m m . ) . L e f t v e n t r i c u l a r p o s t e r i o r w a l l m o t i o n w a s d e c r e a s e d i n all p a t i e n t s (0.76 _+ 0.03 cm.) w i t h n o r m a l p o s t e r i o r w a l l t h i c k n e s s (0.8 _ 0.22 cm.). I n t e r v e n t r i c u l a r s e p t a l t h i c k n e s s was n o r m a l i n a l l 18 p a t i e n t s (0.88 +_ 0.03 cm.). S y s t o l i c t h i c k e n i n g of t h e s e p t u m was a b s e n t i n 13 p a t i e n t s a n d w a s r e d u c e d i n all o t h e r s (3.94 _ 1.60 p e r c e n t ) .
American Heart Journal
S e p t a l m o t i o n w a s a b s e n t or d e c r e a s e d i n 10 p a t i e n t s (Fig. 3), six of w h o m h a d m i l d or n o m i t r a l r e g u r g i t a t i o n . T w o of t h e s e p a t i e n t s h a d left b u n d l e b r a n c h block. F o u r h a d m o d e r a t e m i t r a l regurgitation on the angiogram. Eight p a t i e n t s h a d n o r m a l or i n c r e a s e d s e p t a l m o t i o n (Fig. 4) a n d all of t h e s e p a t i e n t s h a d s i g n i f i c a n t m i t r a l r e g u r g i t a t i o n o n a n g i o g r a p h y (Fig 5). C o r r e c t i o n of s e p t a l m o t i o n for t h i c k e n i n g (passive s e p t a l m o t i o n ) did n o t s i g n i f i c a n t l y c h a n g e the results. S e p t a l s y s t o l i c t h i c k e n i n g w a s 50 +_ 2.41 p e r c e n t ( S . E . M . ) ( r a n g e 30 to 70 p e r c e n t ) i n o u r 20 n o r m a l s u b j e c t s , 73 ___ 2.78 p e r c e n t ( r a n g e 60 t o 86 per c e n t ) i n t h e e i g h t p a t i e n t s w i t h left v e n t r i c u l a r v o l u m e o v e r l o a d , a n d 7 0 _ 7.61 per c e n t ( r a n g e 58 t o 100 p e r c e n t ) i n t h e five p a t i e n t s w i t h c o r o n a r y disease a n d n o r m a l s e p t a .
Discussion I n t h e s e 18 p a t i e n t s w i t h c o n g e s t i v e c a r d i o m y o p a t h y t h r e e f e a t u r e s were c o n s t a n t i n t h e echoc a r d i o g r a m of t h e left v e n t r i c l e , n a m e l y , a d i l a t e d cavity, reduced posterior wall motion, a n d d e c r e a s e d s e p t a l s y s t o l i c t h i c k e n i n g ( T a b l e I). i n
35
Levisman
Fig. 3. Echocardiogram of a patient with congestive cardiomyopathy without mitral regurgitation (Case 12, Table I). Note the absence of both septal motion and systolic thickening. There is also biventricular dilatation. Abbreviations as in Fig. 1.
Fig. 4. Echocardiogram of a patient with congestive cardiomyopathy and severe mitral regurgitation (Case 6, Table I). Note the apparent normal septal motion and no systolic thickening as indicated by the dark lines. 10 p a t i e n t s septal m o t i o n was reduced or a b s e n t as previously reported. In the o t h e r eight p a t i e n t s septal m o t i o n was either " n o r m a l " or increased; however, an a p p a r e n t n o r m a l septal m o t i o n w i t h o u t systolic thickening suggests a passive m o t i o n t h a t is n o t due to c o n t r a c t i o n of the m y o c a r d i u m . I n these eight p a t i e n t s there was significant m i t r a l regurgitation. This v o l u m e
36
overload of the left ventricle m a y m a k e the s e p t u m m o v e passively t o w a r d the right ventricle in diastole during v e n t r i c u l a r filling a n d posteriorly again as the v e n t r i c u l a r v o l u m e decreases in systole. A similar p a t t e r n of septal m o t i o n in congestive c a r d i o m y o p a t h y would p r o b a b l y also be p r o d u c e d b y left v e n t r i c u l a r v o l u m e overload due to a variety of causes.
January, 1977, Vol. 93, No. 1
Echocardiographic diagnosis of mitral regurgitation Four patients with significant mitral regurgitation showed decreased or absent septal motion and there were no detectable echocardiographic findings to suggest mitral regurgitation in these patients. On the other hand, no patient in this series showed apparently normal or increased septal motion in the absence of significant mitral regurgitation. The abnormal pattern of septal motion associated with left bundle branch block 13-15was not seen in the two patients with this conduction defect since contraction of the septum was not detectable. Analysis of septal motion by itself could not distinguish congestive cardiomyopathy with significant mitral regurgitation and passive septal motion from a dilated left ventricle d u e to myocardial infarction with a compensatory increase in septal motion. However, in the former condition there was reduced septal systolic thickening whereas the latter showed increased septal systolic thickening (Fig. 6), Volume overload of the left ventricle with normal or hypertrophied myocardium would also increase septal systolic thickening (Fig. 7). Reduced septal systolic thickening has been observed in hypertrophic cardiomyopathy.11 In this entity asymmetric hypertrophy of the septum and normal or small LV cavity size permit little difficulty in differential diagnosis. Reduced septal thickening is also a feature of infiltrative cardiomyopathy such as t h a t due to amyloid. TM Increased septal and posterior wall thickness and a small left ventricular cavity in this syndrome make it easily recognizable. An abnormal aortomitral "discontinuity" has been proposed as indirect evidence for mitral regurgitation? 2 We found an abnormally increased value in the 17 patients with congestive cardiomyopathy in whom it could be measured regardless of mitral valve competence, and it is probably related merely to dilatation of the left ventricle and to transducer position on the chest wall. Our study does not support previous observations of abnormal systolic motion of the mitral valve as evidence of mitral insufficiency in congestive cardiomyopathy.16 These observations confirm previous studies on congestive cardiomyopathy which have shown that a dilated left ventricle with normal wall thickness and reduced septal and posterior wall motion are the major echocardiographic features
American Heart Journal
1.2-
9
1.0--
.-g u
O0
0.8-
Z
o ~o .._]
<
0.60.4-
I-0._ I..d
u~
0.20.1O0
I
NONE
O0 I
O0 I
I
MILD MODERATE SEVERE
MITRAL REGURGITATION (ANGIOGRAPHY) Fig,
5.
Diagram showing the correlation between septal
motion and degreeof mitral regurgitation.The verticaldashed line separates the cases with no or mild regurgitation from moderate and severe. The horizontaldashed line is drawnjust below the lower limit of normal septal motion.
of this syndrome. We further suggest that an apparently normal or increased septal motion with reduced or no septal systolic thickening is also compatible with congestive cardiomyopathy and when present is evidence for coexistent left ventricular volume overload usually due to significant mitral regurgitation. Reduced or absent septal systolic thickening distinguishes this syndrome from segmental myocardial disease with intact septal function.
Summary Eighteen patients with congestive cardiomyopathy were studied by echocardiography and cardiac catheterization. Patients with coronary disease on angiography or primary valvular disease were excluded. Six patients showed mild or no mitral regurgitation; in 12 others the degree of mitral regurgitation was moderate or severe. The echocardiographic features in these patients were: (1) a dilated left ventricle (LV), (2) normal LV wall thickness, (3) reduced LV posterior wall motion, and (4) reduced or absent systolic thickening of the interventricular septum
(IVS). IVS motion was reduced in 10 patients, and
37
Levisman
Fig. 6. Echocardiogram of a patient with a posterior myocardial infarction. Septal systolic thickening is 100 per cent as indicated by the dark lines. The posterior wall motion is reduced.
Fig. 7. Echocardiogram of a patient with combined aortic sten0sis and insufficiency. The septal systolic thickening is 75 per cent, Note the concentric hypertrophy of the left ventricle, dilated left ventricular cavity, and prominent atrial deflection in the septum. a p p e a r e d " n o r m a l " o r i n c r e a s e d in a n o t h e r e i g h t , all of whom showed moderate or severe mitral regurgitation on angiography. I t is c o n c l u d e d t h a t a n a p p a r e n t n o r m a l o r increased motion of the IVS with reduced or a b s e n t s y s t o l i c t h i c k e n i n g in c o n g e s t i v e c a r d i o 38
m y o p a t h y i s e v i d e n c e f o r c o e x i s t e n c e o f significant mitral regurgitation. = Reduced or absent systolic thickening can distinguish these patients from those with segmental myocardial disease and normal septa or dilated LV's due to volume overload.
January, 1977, Vol. 93, No. 1
Echocardiographic diagnosis of mitral regurgitation The author wishes to thank Drs. Rex N. MacAlpin and Abdul S. Abbasi for their advice and encouragement, Drs. Cornelius J. Bos and Bruce M. Barack for reviewing the angiograms, Mrs, Nancy Ellis for technical assistance, and Mrs. Rita Bachtold and Mrs. Pat Ritter for the secretarial support. REFERENCES
1. Abbasi; A. S., Chahine, R. A., MacAlpin, R. N., and Kattus, A. A.: Left ventricular function in congestive cardiomyopathy, Chest 62:357, 1972. 2. Abbasi, A. S., Chahine, R. A., MacAlpin, R. N., and Kattus A. A.: Ultrasound in the diagnosis of primary congestive cardiomyopathy, Chest 63:937, 1973. 3. Corya, B. C., Feigenbaum, H., Rasmussen, S., and Black, M. J.: Echocardiographic features of congestive cardiomyopathy compared with normal subjects and patients with coronary disease, Circulation 49:1153, 1974. 4. Assad-Morell, J. L,, Tajik, A. J., and Giuliani, R. R.: Echocardiographic analysis of the ventricular septum, Prog. Cardiovasc. Dis. 17:219, 1974. 5. Abbasi, A. S., MacAlpin, R. N., Eber, L. M., and Pearce, M. L.: Echocardiographic diagnosis of idiopathic hypertrophic cardiomyopathy without outflow tract obstruction, Circulation 46"897, 1972. 6. Abbasi, A. S., MacAlpin, R. N., Eber, L. M., and Pearce, M. L.: Left ventricular hypertrophy diagnosed by echocardiography, N. Engl. J. Med. 289:118, 1973. 7. Henry, W. L., Clark, C. E., and Epstein, S. E.: Asymmetric septal hypertrophy (ASH). Echocardiographic identification of the pathognomonic anatomic abnormality of I.H.S.S., Circulation 47:225, 1973.
American Heart Journal
8. Tajik, A. J., and Giuliani, R. R.: Echocardiographic observations in idiopathic hypertrophic subaortic stenosis, Mayo Clin. Proc. 49:89, 1974. 9. Abbasi, A. S., Ellis, M., and Child, J. C.: Echocardiographic features of infiltrative cardiomyopathy, J. Clin. Ultrasound 2:221, 1974. 10. Levisman, J. A., Child, J. C., Abbasi, A. S, and MacAlpin, R. N.: Echocardiographic findings in amyloid heart disease, Circulation (abstr.) 52:II-208, 1975. 11. Rossen, R. M., Goodman, D. J., Ingham, R. E., and Popp, R. L.: Ventricular systolic septal thickening and excursion in idiopathic hypertrophic subaortic stenosis, N. Engl. J. Med. 291:1317, 1974. 12. Johnson, M. L., Kisslo, J., Warren, S. G., and Behar, V. S.: Echocardiographic diagnosis of mitral apparatus dysfunction with mitral insufficiency, J. Clin. Ultrasound 2:237, 1974. 13. Dillon, J. C., Chang, S., and Feigenbaum, H.: Echocardiographic manifestations of left bundle branch block (abst.), Circulation 48 (Suppl. IV)IV-126, 1973. 14. McDonald, I. G.: Echocardiographic demonstration of abnormal motion of the interventricular septum in left bundle branch block, Circulation 48:272, 1973. 15. Abbasi, A. S., Eber, L. M., MacAlpin, R. N., and Kattus, A. A.: Paradoxical motion of the interventricular septum in left bundle branch block, Circulation 49:423, 1974. 16. Wilward, D. K., McLaurin, L. P., and Craige, E.: Echocardiographic studies of the mitral valve in patients with congestive cardiomyopathy and mitral regurgitation, AM. HEART J. 85:413, 1973.
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