Imaging in Obstructive Hypertrophic Cardiomyopathy

This article is part of CTSNet’s Guest Editor Series, “Operative Management of Obstructive Hypertrophic Cardiomyopathy—Gold Standard Septal Myectomy to Stand the Test of Time.” Guest editor Eduard Quintana has curated a robust collection of content that shares the knowledge, techniques, and insights of several distinguished experts from around the world. See the full series here.

This video discusses the role of multimodality imaging (echocardiography and cardiac magnetic resonance or CMR) in identifying various phenotypes of hypertrophic cardiomyopathy (HCM) patients who demonstrate dynamic LV outflow tract obstruction.

It highlights the importance of precise wall thickness measurements to adequately plan surgical myectomy. This might require a combination of echo and CMR. It further demonstrates the importance of evaluating the direction of the jet of mitral regurgitation in identifying the precise etiology. Additionally, it is important to recognize that not all obstructive HCM patients have severe basal septal hypertrophy. Some patients have significant abnormalities in mitral leaflets and/or papillary muscles that results in LV outflow tract obstruction. Using multimodality imaging, such abnormalities can be easily identified. This can help precise procedural planning for optimal relief of LV outflow tract obstruction. Surgical planning in such cases should be tailored using detailed multimodality imaging. Doing so results in excellent outcomes. 

References

1. Outcomes in Guideline-Based Class I Indication Versus Earlier Referral for Surgical Myectomy in Hypertrophic Obstructive Cardiomyopathy. Alashi A, Smedira NG, Hodges K, Popovic ZB, Thamilarasan M, Wierup P, Lever HM, Desai MY. J Am Heart Assoc. 2021 Jan 5;10(1):e016210. doi: 10.1161/JAHA.120.016210.
2. Comparison of Ventricular Septal Measurements in Hypertrophic Cardiomyopathy Patients Who Underwent Surgical Myectomy Using Multimodality Imaging and Implications for Diagnosis and Management. Phelan D, Sperry BW, Thavendiranathan P, Collier P, Popović ZB, Lever HM, Smedira NG, Desai MY. Am J Cardiol. 2017 May 15;119(10):1656-1662.
3. Left Ventricular Outflow Tract Obstruction in Hypertrophic Cardiomyopathy Patients Without Severe Septal Hypertrophy: Implications of Mitral Valve and Papillary Muscle Abnormalities Assessed Using Cardiac Magnetic Resonance and Echocardiography. Patel P, Dhillon A, Popovic ZB, Smedira NG, Rizzo J, Thamilarasan M, Agler D, Lytle BW, Lever HM, Desai MY. Circ Cardiovasc Imaging. 2015 Jul;8(7):e003132. doi: 10.1161/CIRCIMAGING.115.003132.
4. Cardiac magnetic resonance in hypertrophic cardiomyopathy. To AC, Dhillon A, Desai MY. JACC Cardiovasc Imaging. 2011 Oct;4(10):1123-37. doi: 10.1016/j.jcmg.2011.06.022.
5. Characteristics and surgical outcomes of symptomatic patients with hypertrophic cardiomyopathy with abnormal papillary muscle morphology undergoing papillary muscle reorientation. Kwon DH, Smedira NG, Thamilarasan M, Lytle BW, Lever H, Desai MY. J Thorac Cardiovasc Surg. 2010 Aug;140(2):317-24. doi: 10.1016/j.jtcvs.2009.10.045. Epub 2009 Dec 28.
6. Steep left ventricle to aortic root angle and hypertrophic obstructive cardiomyopathy: study of a novel association using three-dimensional multimodality imaging. Kwon DH, Smedira NG, Popovic ZB, Lytle BW, Setser RM, Thamilarasan M, Schoenhagen P, Flamm SD, Lever HM, Desai MY. Heart. 2009 Nov;95(21):1784-91. doi: 10.1136/hrt.2009.166777.
7. Abnormal papillary muscle morphology is independently associated with increased left ventricular outflow tract obstruction in hypertrophic cardiomyopathy. Kwon DH, Setser RM, Thamilarasan M, Popovic ZV, Smedira NG, Schoenhagen P, Garcia MJ, Lever HM, Desai MY. Heart. 2008 Oct;94(10):1295-301. doi: 10.1136/hrt.2007.118018.

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