Hypertrophy Obstructive Cardiomyopathy.pptx

HOCM

1. Hypertrophy obstructive cardiomyopathy An Echo Case Vignette

2. PATIENT IDENTITY Name : Mr. Muh Rifal Syahid Sex : Male Date of birth : 13 -08-1996 / 25 y.o MR : 981113 Address : Bulukumba Occupation : Tailor Phone : [phone]

3. BRIEF HISTORY TAKING AND PHYS EXAMINATION Chief complaint : Exertional chest discomfort and dyspneu since 5 years ago , relieved with rest , PND ( - ) Orthopneu (-), no follow up treatment. In the last one year, patient was readmitted with same complain, Patient was advised to go Cardiac Center RSWS for further treatment. Patient had loss of consciousness twice during heavy activities. Risk factor : Family history (mother and aunt were died at 40 years old with heart disease) Hypertension (-), smoking (-), DM (-) BP : 118/73 mmHg Pulse : 64 bpm RR : 18 tpm T : 36. 4 Conjunctiva: not anemic Sclera: not icteric JVP R+2 cmH2O Thorax : Breath sound Vesiculer , rhonki (-), wheezing (-) Thorax : Breath sound Vesiculer , rhonki (-), wheezing (-) Cor : S1/S2 regular, systolic murmur at apex grade III/VI Extremities: warm

4. ELECTROCARDIOGRAPHY Mitral P wave: LA enlargement Cornell Criteria: R wave at aVL + S wave at V3 > 28 mm (36 mm) on 10mm/mV amplitude; LVH Inverted T wave at high lateral wall (I, aVL )

5. ECHOCARDIOGRAPHY To ensure that this case is HOCM, we must pay attention to this parameter: Prove that this is HCM Wall thickness (more than 15 mm, symmetrical/ assymetrical , IVS morphology) Mitral valve (morphology, SAM, MR and its characteristics) Diastolic dysfunction/increased LA filling pressure Prove that there is obstruction at LVOT => CW and M-Mode at PLAX View Gradient more than 30 mmHg either at rest or provoked Dagger shaped wave M-Mode at Mitral and Aortic Valves : SAM, Aortic valve mid-systolic partial closure

6. WALL THICKNESS, IVS MORPHOLOGY BASAL MID APICAL All LV segments show sufficient wall thickness (≥ 15 mm) in every wall region Thus, symmetrical Morphology: Neutral HCM OTHER MORPHOLOGIES

7. MITRAL VALVES Systolic Anterior Motion: AML moves touching IVS, during systole AML: elongated, thickening Chordae: elongation, hypermobility MR: eccentric to lateral wall, impression moderate, due to SAM

8. INCREASED LV FILLING PRESSURE E/A: diastolic dysfunction, E/E’ lateral > 10 (14,36) Ar – A duration > 30 msec LV Diastolic Dysfunction + MR => increased LA dimension TR present PASP : > 30 mmHg (74,58 mmHg)

9. LVOT OBSTRUCTION/CW LVOT LVOT CW gradient on the patient > 30 mmHg (36 mmHg) at rest. CW Gradient > 30 mmHg Dagger shaped CW Gradient on standing: 45 mmHg CW Gradient can be increased further by these: Standing Exercise Valsava maneuver

10. LVOT OBSTRUCTION Aortic valve mid-systolic partial closure seen on Aortic Box M-mode Systolic anterior motion on patient Red arrow: on patient Systolic anterior motion best confirmed on Mitral M-Mode

11. HYPERTROPHY OBSTRUCTIVE CARDIOMYOPATHY (HOCM) CONCLUSION:

12. Therapy Bisoprolol 5 mg/24 hours/oral Minimun activities

13. SURGERY CONSIDERATION LVOTO in HCM is diagnosed at > 30 mmHg, but surgical intervention is at > 50 mmHg Ablation vs Myectomy? Septal ablation may be less effective in patients with extensive septal scarring on CMR and in patients with very severe hypertrophy ( ≥ 30 mm) Risk of ventriculoseptal defect following septal alcohol ablation and septal myectomy is higher in patients with mild hypertrophy (≤16 mm) at the point of the mitral leaflet–septal contact Mitral surgery? The length of the anterior leaflet of the mitral valve >16 mm/m2 is considered elongated, may contribute to obstruction, and may require leaflet plication.

14. THANK YOU