00:01
Let's go to the next one.
00:02
Less common, still an important cause,
genetic cause of cardiomyopathy.
00:08
And it's the flip side of the coin.
00:09
Remember dilated cardiomyopathy -
floppy heart, poor systolic function.
00:14
Hypertrophic cardiomyopathy - really thick muscle,
you know, well, muscled heart doesn't relax.
00:22
Okay?
So it's a diastolic dysfunction, there's
impaired left ventricular relaxation and filling,
and that can be as bad as poor
left ventricular ejection fraction.
00:34
What we see grossly is that there's a thick
walled heavy and hypercontractile heart.
00:41
The mutations that cause this tend to make
the sarcomere squeeze more efficiently,
but relax more poorly.
00:50
The systolic function is usually preserved.
00:52
If anything, it may be increased.
00:54
So in dilated cardiomyopathy, we're talking
about ejection fractions of 20 to 30%.
00:59
The systolic function in a hypertrophic
cardiomyopathy can be 60, 70, sometimes even 80%.
01:04
So we're squeezing very aggressively.
01:08
The mutations for the most part, the vast
majority, and this is what will be on the boards,
you don't have to remember
a lot of the exceptions.
01:15
Most mutations will involve
the myosin heavy chain.
01:19
So it's indicated here as an
X, we actually don't delete it.
01:23
We have mutations in it so that
the heads of the myosin heavy chain
bind with greater affinity
to the actin light chain,
and we get hypercontractile forces generated.
01:37
So that's the majority of them.
01:38
There are other mutations, as
we'll briefly mention later on.
01:42
The hypertrophy is most apparent
within the left ventricle.
01:49
It is also happening within the right ventricle.
01:51
But it's the left ventricle that squeezes
most vigorously in the first place,
and so it's going to be the one that
we're going to see most of the effects.
01:59
So there's something called asymmetric septal
hypertrophy, where there is a more prominent
septal hypertrophy compared to
the left ventricular free wall.
02:08
And you see there, the septum is markedly
thickened, that gives the ventricular cavity
a banana-like configuration.
02:16
This septal hypertrophy impinges
on the left ventricular outflow
and the aortic valve there is
actually can be somewhat compromised
as we'll show in a subsequent set of slides.
02:27
So it can be an obstructive cardiomyopathy,
typically with asymmetric septal hypertrophy.
02:33
You can also have concentric hypertrophy,
which is the less common kind of variant,
where the entire wall is relatively thickened.
02:42
The ventricular chamber is smaller
because the wall has gotten much thicker.
02:47
It also doesn't relax at all well, so
that chamber remains reasonably small.
02:52
This concentric hypertrophy is less likely to
have left ventricular outflow tract obstruction,
and it doesn't really have that
same banana-like configuration,
but it's a non classic variant
of hypertrophic cardiomyopathy.
03:07
So the non-obstructive hypertrophic
cardiomyopathy occurs in about 65 to 75%.
03:15
It's shown here, as that septal hypertrophy.
03:19
You can still have septal hypertrophy without
actually formally having outflow tract obstruction.
03:25
But if we're going to get outflow tract
obstruction, it's going to be with this
asymmetric hypertrophy of the left ventricle.
03:33
With the obstructive form, which is roughly a
third of these asymmetric septal hypertrophy,
the involvement of the interventricular
septum increases more and more and more,
and now we are compromising the
outflow through the aortic valve.
03:48
So this is going to be obstructive
hypertrophic cardiomyopathy
or hypertrophic obstructive
cardiomyopathy called HOCM
Alright, and that is a very dynamic left
ventricular outflow tract with an obstruction.
04:02
So let's look at a little bit more detail
when we talk about obstructive cardiomyopathy
or hypertrophic obstructive
cardiomyopathy or HOCM.
04:10
You can see that as the septum gets
thicker and thicker and thicker
in the asymmetric septal hypertrophy setting,
we will now impinge on the outflow tract
because the anterior mitral leaflet,
gets pulled by turbulence by a hyperdynamic flow
going out the left ventricular outflow tract
and will get pulled towards the septum.
04:35
This gives us what is called systolic
anterior motion of the mitral leaflet
that is seen on echocardiogram, and
that gives us this premature closure
of the left ventricular outflow tract is that
anterior leaflet as pulled up against the septum.
04:52
We can see that grossly when we're
holding the heart in our hands
as a plaque of fibrous connective
tissue, intimal hyperplasia where the
anterior leaflet has slapped up
against the interventricular septum
over and over and over again.
05:07
And this is where we get that
obstructive cardiomyopathy result.
05:12
So it causes left ventricular
outflow tract obstruction
with premature closure of the
left ventricular outflow tract.
05:17
And we will get because of that slapping
motion and the trauma associated with that,
we will get overall thickening
of the mitral leaflet.
05:25
Because the mitral valve is now being
pulled towards the septum during systole,
that means, as the heart squeezes very
hyperdynamically, we're going to have retrograde
regurgitant flow back out through
the mitral valve apparatus.
05:45
So hypertrophic obstructive cardiomyopathy
has diminished left ventricular outflow,
premature closure, damage to the mitral
valve, anterior leaflet and regurgitant flow
so you can have significant
heart failure in that setting.