Presentation
Shortness of breath with associated easy fatigability on mild exertion.
Patient Data
There is right perihilar and para-cardiac opacification. The heart is enlarged. The arch of the aorta is partly calcified and the aorta unfolded.
The upper lobe pulmonary vessels are prominent .A left lamellar effusion is seen. A right subpulmonic pleural effusion is seen .
The bony cage is normal.
Dilated left ventricle with paradoxical wall motion of the interventricular septum (IVS). There is a beak-like projection of the IVS in M-mode (see white arrows on annotation) in early systole which is produced as a result of movement of the IVS towards the left ventricle in early systole and followed by immediate backward retraction away from the center of the left ventricle.
Severely reduced left ventricular systolic function. LVEF 20%. Dilated left atrium
Mild to moderate mitral regurgitation. Moderate to severe aortic regurgitation, aortic insufficiency, PHT:241 ms. Mild tricuspid regurgitation. Mild pericardial effusion.
Normal right-sided chambers with good longitudinal right ventricular systolic function.
Case Discussion
It is unusual for left bundle branch block (LBBB) to exist in the absence of organic disease. Causes are varied and dilated cardiomyopathy is one of the associations. LBBB is a form of interventricular conduction defect. In normal cardiac conduction, impulses travel equally down the left and right bundles, with the septum activated from left to right. In LBBB, conduction delay means that impulses travel first via the right bundle branch to the right ventricle, and then to the left ventricle via the septum, septal activation is thus reversed.
In echocardiography, regional wall motion abnormalities are often easier to recognize suggesting coronary artery disease or non-coronary scenarios. LBBB is recognized by a septal beaking (septal flash) which means early inward septal motion is seen prior to posterolateral wall motion due to septal-lateral dyssynchrony.