Letter boxA delightful 74 year old lady presents to your hospital stating she is having difficulty walking to her letter box. The letter box is about 30m from her front door. The problem has been getting worse over months, but has got particularly bad the last few weeks. Luckily for you she presented on your shift and you are armed with your echo.

Her past medical history is unremarkable except for lymphoma, for which she underwent adriamycin chemotherapy 2 years prior. She take no regular medications.

You perform a TTE:

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PLAX showing severely dilated LV,  almost circular in shape, with thinning of the LV walls. Systolic function is severely reduced, but there is some basal inferolateral wall preservation. Left atrium also appears dilated.

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PSAX view through the base of the LV (mitral valve leaflets can be seen). This shows severely dilated and impaired LV function. The septum appears almost akinetic with no thickening, and the rest appears globally reduced.

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AP4C view showing severely dilated left ventricle with severely reduced systolic function. Ejection fraction is approximately 15%. Right ventricle is also severely dilated with severely reduced systolic function. Contraction of the septum appears dyssynchronous with the lateral wall. Both atria are also enlarged. Note the mitral and tricuspid valve opening  is not vigorous, which can indicate a low cardiac output.

AP4C Dilated Atria

Biatrial enlargement suggests a dilated cardiomyopathy that has been present for some time.

You diagnose a severe dilated cardiomyopathy. Dilated Cardiomyopathies (DCM) are usually divided into two main groups – ischaemic and non ischaemic DCM. Some common causes include:

  • Ischaemic (commonest – look for RWMA’s)
  • Ideopathic/Familial (may spare basal inferolateral wall)
  • Myocarditis (low EF with normal or increased mural thickness > 12mm)
  • Congenital  (complex malformations)
  • Non compaction
  • Toxic: post chemotherapy e.g. adriamycin, ETOH (history may point to this)

Echocardiographic features include

  • 4 chamber enlargement
  • Severe systolic dysfunction of the LV, usually with at least moderate LV dilatation.
  • LV diastolic dysfunction, often severe.
  • RV may be spared with predominant left sided changes.
  • Biatrial dilatation
  • Functional MR is common, related to changes in chordal attachments and annular dilatation.
  • Dyssynchrony (interventricular, or atrioventricular) may be pronounced and contribute to mechanical inefficiency.
  • Apical clot is common as well – see LV thrombus
  • Left pleural effusions can be see, especially on deep PLAX view

Examples of complications of DCM on echocardiography:

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TTE PLAX (deep gastric view) showing  a relative absence of echogenic material deep to the heart, as well as several B lines. This is consistent with a large left pleural effusion 

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PLAX zoom on the mitral valve, showing minimal apposition of the anterior and posterior mitral valve leaflets, and severe MR with colour Doppler.  

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AP4C zoom on LV Apex, revealing a large clot that was missed in the standard view. This complication needs to be looked for. 

Sonographer Tips:

As the heart enlarges, it often becomes more spherical and lateral. Sometimes a more atypical lateral approach is need to optimise your image.

Very dilated hearts may not fit in your echo field – you may need to widen your field, or use multiple windows.

This lady was diagnosed with a severe DCM. The cause may have been a complication of her Adriamycin chemotherapy, though this is usually not as severe. An idiopathic DCM was eventually diagnosed. She was commenced on diuretics, fluid restriction, an ACE inhibitor and β-blocker. Her symptoms gradually improved over the next 6 months, and at 12 months she felt much better, though her exercise tolerance remained reduced.

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