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Significance of left ventricular pronounced trabeculations in a patient with recurrent decompensated heart failure

Session Poster Session 4

Speaker Alexandra-Maria Chitroceanu

Event : Heart Failure 2019

  • Topic : valvular, myocardial, pericardial, pulmonary, congenital heart disease
  • Sub-topic : Dilative Cardiomyopathy
  • Session type : Poster Session

Authors : AM Chitroceanu (Bucharest,RO), N Patrascu (Bucharest,RO), V Vintila (Bucharest,RO), D Mihalcea (Bucharest,RO), C Stuparu (Bucharest,RO), D Vinereanu (Bucharest,RO)

Authors:
AM Chitroceanu1 , N Patrascu2 , V Vintila2 , D Mihalcea2 , C Stuparu1 , D Vinereanu2 , 1University Emergency Hospital of Bucharest, Cardiology - Bucharest - Romania , 2University of Medicine and Pharmacy Carol Davila - Bucharest - Romania ,

Citation:

Introduction: Pronounced left ventricular (LV) trabeculations are described in dilated and hypokinetic left ventricles as well as in left ventricular non compaction (LVNC). It is unclear if this imaging findings are a distinct pathological entity, or an epiphenomena of LV remodelling.

Case presentation: A 33 year old male was admitted for recurrent decompensated heart failure, with a "wet and warm" profile. He mismanaged his diet and prescribed medications. He was diagnosed with dilated cardiomyopathy (DCM) 3 years before, when he first presented with acute heart failure and was diagnosed with a LV ejection fraction (EF) of 20% and apical thrombus considered to be secondary to myocarditis. Coronary angiography showed normal epicardial coronary arteries. Cardiac magnetic resonance (CMR), performed 4 months after the acute event, detected severely dilated LV, with an EF of 51%. CMR raised suspicion of non-compaction (LVNC), with multiple myocardial trabeculations which fulfill the LVNC criteria at the level of 7 segments, mainly at the apex, anterior, and antero-lateral walls of LV, with no thrombus, scar or fibrosis. At this admission, transthoracic echocardiography confirmed severely dilated LV, with an EDV index of 104 ml/m2, reduced ejection fraction, with an EF of 30%, and global hypokinesia. No thrombus was seen. Ratio of non-compacted /compacted layer was <2. We performed speckle tracking analysis with assessment of peak systolic longitudinal strain (PLS). PLS showed significantly reduced global longitudinal strain (-9.6%) and impaired regional PLS at the level of the anterior and antero-lateral apical and mid-segments (Figure). The patient was managed medically with improvement of symptoms.

Questions, problems or possible differential diagnosis: There is a considerable overlap between LVNC and other cardiomyopathies. Differentiation between LVNC and DCM remains challenging, being based on a careful clinical characterization and imaging (echocardiography and CMR). Complete recovery of cardiac function in a patient with LVNC is unlikely. Also, pathological conditions of volume overload are often associated with a LVNC-like phenotype. Although CMR revealed pronounced trabeculations suggestive for isolated LVNC, those criteria alone have poor specificity for LVNC being also present in asymptomatic population free from cardiovascular disease. Moreover, trabeculations are also describe in myocarditis with a regression after some time. Assessment of myocardial deformation patterns, despite overall hypokinesia with impaired global PLS, showed reduced deformation values in some segments, mimicking a post myocarditis pattern.

Conclusion and implications for clinical practice: Morphological criteria alone are necessary but insufficient for a correct diagnosis of LVNC in young patients with heart failure. Speckle tracking analysis may help to differentiate between the LVNC and pronounced trabeculations in DCM. However, a CMR follow up is mandatory.

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