Where is Waldo on the Echo (Part 2)?

It is not only rewarding to find important information hidden in an echo but also fun! Thanks to our readers for the positive comments to the first part of “Where is Waldo* on the Echo” newsletter. If you did not have a chance to read part 1 here is the link.
*Waldo is also known under the name of “Wally” in certain countries

World’s Largest Gathering of People Dressed as Waldo at Rutgers University.

Are you ready for a fun echo search-game? Yes? Well, then here we go......


Case 1 - Mitral regurgitation so what?

Here is a difficult case: a patient with dilated cardiomyopathy who is in heart failure class III-IV. His left ventricular function is really poor and he also has severe mitral regurgitation. But there is one more thing that is of importance in this patient. We will give you a clue. It has something to do with the “timing of mitral regurgitation” Take a close look:




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Four chamber color Doppler view, showing severe mitral regurgitation.
But what is it about MR that is “strange"?





Case 2 - Poor function – but why?

Before you find the answer at the end of this newsletter, we want to show you the four chamber view of another patient. He also has poor left ventricular function. But, again there is something that should come to your attention.




Aside form the fact that this patient has poor left ventricular function and enlarged
atria, is there any thing else that might be relevant for the patient?

He was not the only one in his family that had cardiomyopathy. Does this little clue help? Take a second look…


Case 3 – A systolic murmur but no aortic stenosis

Finally, here is a hypertensive patient in whom aortic stenosis was suspected, since he had a loud systolic murmur. No, he does not have aortic stenosis. Where is Waldo here?




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Hyperdynamic left ventricular function, left ventricular hypertrophy and left atrial
enlargement are the obvious findings. What else does this patient have?

Did you recognize the additional “problems” that these patients have? Here are the answers and an explanation why these additional findings are important:




Solving case 1

We must confess this one was really hard, but if you looked closely you could see that the duration of regurgitation is quite long. It actually starts before the onset of the QRS complex. You can see this on the CW Doppler tracing of mitral regurgitation shown below. Note that the onset of mitral regurgitation occurs during diastole.


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CW Doppler shows distinct presystolic (diastolic) mitral regurgitation

Diastolic mitral regurgitation occurs fairly frequently in patients with first-degree AV block and reduced left ventricular function. Since end-diastolic pressure in the left ventricle exceeds the pressure in the left atrium the mitral valve is again “pushed” open. Because the AV time is long there is enough time for this to happen before ventricular contraction occurs. Why is this important? Because this problem can be corrected with a pacemaker (you can adjust the AV delay). Our patient was also a candidate for both ICD and cardiac resynchronization therapy (CRT) so the decision to implant a device was quickly made.


Cheesy stuff in case 2

Did you notice the spongy appearance of the lateral myocardium? This finding strongly suggested isolated left ventricular non - compaction syndrome (ILVNC). Here is another view:




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Apical long axis view focusing on the postero-lateral
wall. The myocardium is strongly trabeculated.

Isolated left ventricular non-compaction is a genetic form of cardiomyopathy. This explains why other family members were also diagnosed with cardiomyopathy. The disease carries an increased risk for sudden cardiac death. As a matter of fact, the patient was brought to us after resuscitation. Why is it important to look out for this form of cardiomyopathy? Well, because echo screening of family members should be performed. In addition, one should probably be more "liberal" in implanting an ICD in such patients.




Listening to Waldo – case 3 unraveled

Were you able to explain the systolic murmur in the third case? If you looked closely at the motion of the anterior leaflet of the mitral valve you might have noticed that it shows an awkward motion. It moves towards the interventricular septum during systole. This is also called “SAM” or systolic anterior motion. The problem is that the mitral valve thereby occludes the outflow tract (LVOT).
Here is the CW Doppler tracing that shows you high velocity flow (5m/sec) across the LVOT. This also explains the systolic murmur. The SAM phenomenon is typically found in patients with hypertrophic cardiomyopathy. This example shows you that it can also be present in patients with hypertensive heart disease.



 Typical CW Doppler spectrum in HOCM showing a high velocity
and a "Dagger-shape" 


If you actually found Waldo in all of the examples you are certainly very advanced. If not - no big deal. We will help you to learn more.
Visit us at: 123sonography.com




Recommended articles:
Where is Waldo (Part 1)?
Causes of Aortic Regurgitation
True or False