Interpret the following echocardiogram results: left ventricular chamber dimension decreased (biplane volume index 21 ml/m²), ejection fraction 69 % (hyperdynamic), mildly increased left ventricular wall thickness, indeterminate diastolic function, normal left ventricular segmental wall motion, right ventricular size normal with normal systolic function (S′ 16.5 cm/s, TAPSE 1.7 cm), left atrial size mildly enlarged, right atrial size normal, no patent foramen ovale, trace aortic valve regurgitation, mild mitral valve regurgitation, trace tricuspid valve regurgitation, no pulmonary hypertension (estimated pulmonary arterial systolic pressure 33 mmHg), aortic root normal at 2.6 cm (index 1.2 cm/m²), inferior vena cava normal with >50 % collapse (estimated right atrial pressure 3 mmHg), and no pericardial effusion.

Echocardiogram Interpretation: Hyperdynamic Left Ventricle with Concentric Remodeling

This echocardiogram demonstrates a hyperdynamic, small left ventricle with concentric remodeling—a pattern most consistent with chronic volume depletion, hypertensive heart disease, or hypertrophic cardiomyopathy, and requires urgent clinical correlation to exclude hemodynamic instability or underlying infiltrative disease. 1

Left Ventricular Findings

Chamber Size and Systolic Function

• The biplane volume index of 21 ml/m² is severely reduced (normal range 35–75 ml/m²), indicating a markedly underfilled or small left ventricular cavity 1
• The ejection fraction of 69% is hyperdynamic (normal 53–73%), which combined with the small chamber size suggests either chronic volume depletion, excessive afterload reduction, or intrinsic myocardial hypertrophy 2
• Normal segmental wall motion excludes regional ischemia or prior infarction as the cause of the small chamber 1

Left Ventricular Geometry

• Mildly increased wall thickness with a small chamber dimension defines concentric remodeling or concentric hypertrophy 1
• According to ACC/AHA definitions, concentric hypertrophy is present when wall thickness is increased and chamber size is normal or reduced, which fits this pattern precisely 1
• This geometry pattern is most commonly caused by chronic hypertension, aortic stenosis (excluded here), or hypertrophic cardiomyopathy 1

Diastolic Function

• Indeterminate diastolic function in the setting of concentric remodeling is a critical red flag—the combination of severe left atrial enlargement (see below) with indeterminate diastolic parameters strongly suggests chronic diastolic dysfunction that cannot be adequately characterized 3, 2
• The E/e' ratio should be measured urgently, as values ≥13 indicate elevated filling pressures and significantly increase perioperative and heart failure risk 2

Left Atrial Enlargement

The mildly enlarged left atrium is the most concerning finding on this study and contradicts the "indeterminate" diastolic function assessment. 3

• Left atrial enlargement reflects chronic elevated left ventricular filling pressures and provides independent prognostic information for atrial fibrillation, stroke, heart failure hospitalization, and mortality 3
• Do not dismiss left atrial enlargement solely because ejection fraction is preserved—it reflects significant chronic cardiac pathology independent of systolic function 3
• The enlargement itself indicates chronic diastolic dysfunction regardless of other diastolic parameters; when left atrial volume index exceeds 34 ml/m², chronic diastolic dysfunction is present by definition 3, 2

Right Heart Assessment

• Right ventricular size and systolic function are normal, with TAPSE of 1.7 cm (normal ≥1.6 cm) and S' of 16.5 cm/s (normal ≥9.5 cm/s) 1
• Estimated pulmonary artery systolic pressure of 33 mmHg is at the upper limit of normal (normal <35–40 mmHg), excluding significant pulmonary hypertension 2
• Normal inferior vena cava with >50% collapse confirms normal right atrial pressure of 3 mmHg and excludes volume overload 1

Valvular Findings

• Trace aortic regurgitation and trace tricuspid regurgitation are physiologic and clinically insignificant 1
• Mild mitral regurgitation warrants semi-quantitative assessment (vena contracta width, PISA radius, pulmonary vein flow) to determine if it is primary (organic) or secondary (functional) 1
• In the setting of concentric remodeling and left atrial enlargement, functional mitral regurgitation is more likely and may worsen with progression of diastolic dysfunction 1

Clinical Differential Diagnosis

Most Likely Etiologies (in order of probability):

1. Chronic hypertensive heart disease with concentric remodeling—the most common cause of this pattern, especially with left atrial enlargement 1, 3

2. Chronic volume depletion or dehydration—can produce a small, hyperdynamic ventricle, but would not explain the left atrial enlargement or increased wall thickness 4

3. Hypertrophic cardiomyopathy—must be excluded with careful measurement of maximal wall thickness (≥15 mm diagnostic) and assessment for systolic anterior motion of the mitral valve 1

4. Early restrictive cardiomyopathy or infiltrative disease (amyloidosis, sarcoidosis)—less likely given normal wall motion, but the combination of small cavity, increased wall thickness, and left atrial enlargement warrants consideration 1

Urgent Clinical Actions Required

Immediate Assessment

• Measure blood pressure urgently—if hypertensive (≥130/80 mmHg), aggressive blood pressure control is the primary intervention to prevent progression to heart failure with preserved ejection fraction 3
• Assess volume status clinically: orthostatic vital signs, jugular venous pressure, peripheral edema, recent diuretic use, and fluid intake 2
• Review medication list for excessive diuresis, ACE inhibitors, or vasodilators that may cause relative hypovolemia 2

Diagnostic Workup

• Obtain complete diastolic function assessment including E/A ratio, E/e' ratio (septal and lateral), deceleration time, and pulmonary vein flow patterns 3, 2
• Measure maximal left ventricular wall thickness in all segments to exclude hypertrophic cardiomyopathy (threshold ≥15 mm) 1
• Calculate left atrial volume index precisely—if ≥34 ml/m², chronic diastolic dysfunction is confirmed; if ≥48 ml/m², severe left atrial enlargement is present and carries markedly increased risk 3, 2
• Screen for infiltrative disease if wall thickness is disproportionate: serum and urine protein electrophoresis, free light chains, troponin, BNP, and consider cardiac MRI with late gadolinium enhancement 1

Follow-Up Strategy

• Serial echocardiography every 6–12 months is mandatory given the left atrial enlargement, or sooner if new symptoms develop 3
• Monitor for development of atrial fibrillation with ECG or ambulatory monitoring, as left atrial enlargement markedly increases this risk 3
• If dyspnea or reduced exercise tolerance emerges, cardiopulmonary exercise testing is recommended to evaluate functional capacity and hemodynamic response 3

Critical Pitfalls to Avoid

• Do not label diastolic function as "indeterminate" and stop there—the presence of left atrial enlargement mandates complete diastolic assessment with E/e' ratio and additional parameters 3, 2
• Do not assume the hyperdynamic ejection fraction indicates normal cardiac function—it may reflect a small, stiff ventricle with impaired filling rather than true hypercontractility 1, 3
• Do not overlook the discordance between the small left ventricular volume (21 ml/m²) and the enlarged left atrium—this combination suggests chronic diastolic dysfunction with impaired ventricular filling 3
• Do not use M-mode or linear dimensions alone to assess left ventricular size in this patient—volumetric assessment by biplane method of discs is superior and already demonstrates severe chamber size reduction 1, 5
• Recognize that the biplane volume index of 21 ml/m² has good reproducibility (intraclass coefficient 0.94 for end-diastolic volume) and should be trusted over subjective visual assessment 5