Cardiomyopathy, Pericardial Disease, and Congenital/Acquired Pathology
Recognizing the classic patterns
Hypertrophic cardiomyopathy: asymmetric septal hypertrophy ≥15 mm (≥13 mm in relatives), systolic anterior motion of the mitral leaflet, dynamic LVOT obstruction (gradient ≥30 mmHg at rest or with provocation), mid-systolic aortic valve notching, and apical hypertrophy with a spade-shaped cavity.
Dilated cardiomyopathy: LV dilatation with EF <45%, global hypokinesis, and functional regurgitation. Restrictive physiology (amyloid, sarcoid, radiation) shows biatrial enlargement with normal or small ventricles, E/A >2, high E/e′, and low e′ velocities; amyloid also produces a granular appearance and relative apical sparing of longitudinal strain. Takotsubo shows apical ballooning with basal hyperkinesis.
Pericardial disease: tamponade is a clinical diagnosis supported by early diastolic right atrial and diastolic right ventricular collapse, a plethoric IVC, and >25% respiratory variation in mitral inflow. Constriction shows a septal bounce, annulus reversus (medial e′ > lateral e′), expiratory diastolic flow reversal in hepatic veins, and respiratory variation in mitral inflow.
Congenital and acquired lesions: secundum ASD with right heart enlargement (sinus venosus defects need TEE); bicuspid aortic valve with root dilatation; coarctation with a suprasternal gradient and diastolic run-off; Ebstein anomaly with apical displacement of the septal tricuspid leaflet.
Traps: "sparkling" myocardium is nonspecific, pleural and pericardial fluid are separated by the descending aorta, and tamponade physiology can occur with a modest effusion.
Rule of thumb: E/e′ >14, medial e′ <7 cm/s, and TR velocity >2.8 m/s together signal elevated filling pressure.