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    Is interventricular septum thickness of 0.6 cm normal in a child?

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Posted on Wed, 16 Aug 2017 in Hypertension and Heart Disease
Question: We have a family history of HCM on my father's side,however my father (56 years old) doesn't have HCM,i (29 years old) have had an echo and no sign of hcm was noted with normal wall thickness. My 27 year old brother is also negative for HCM by echo and ecg.
I also got my 3 and a half year old son tested (he is normal and no symptoms at all). Doctor said his echo is normal with a thickness of 0.6cm on m mode measurement and 0.5cm on a more focused one (i believe 2D) which doctor said is more accurate. Would a 0.6cm thickness on m mode for a 3 and a half year be considered normal or on high end? Reference values are only for adults.

I am worried that for his age 0.6cm is high and as he grows older it will get much thicker. What is the rate of thickness growth for a normal healthy child per year or over time ?
doctor
Answered by Dr. Ilir Sharka 1 hour later
Brief Answer:
I would explain as follows:

Detailed Answer:
Hello!

Welcome and thank you for asking on HCM!

Regarding your concern, I would explain that it is difficult to judge on the normality of the ventricular wall thickness based only on the child age.

It is quite usual to find different body size and thus body surface areas in the children of the same age.

That's why a normal myocardial thickness in a child with a greater body size area may be considered abnormally increased in another smaller child (with a smaller body size).

So, it is necessary to know the exact body weight and height in order to properly judge on the ventricular wall size.

Please, could you provide me with your son's body weight and height?

I would be able to give a more professional opinion on your son's echo reports.

Hope to have been helpful!

I remain at your disposal for any further discussion.

Kind regards,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 34 minutes later
His weight is 15 kg and his height is 39 inches.
doctor
Answered by Dr. Ilir Sharka 14 hours later
Brief Answer:
Opinion as follows:

Detailed Answer:
Hello again, dear XXXX!

Considering the actual body size (BSA 0.636 cm2), the average interventricular septum thickness would be around 4.75 mm (range 3,25 - 6.25). So your child is quite a bit above the average value, but you should relax as the value is also within the normal range.

So the value can still be considered normal.

What is more important is the need for a periodic echo follow-up to check the rate of wall thickness increase.

There is no any predetermined proportion of interventricular septum increase over age, but there exist charts that present percentiles of increase over the full body surface area range.

Hope to have clarified your concern!

In case of any further uncertainties, feel free to ask me again.

Kind regards,

Dr. Iliri

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 8 minutes later
May you please provide me with the formula you based your answer on and the reference for it ?

I have found several regression equations and the average for his age has been 5.7 to 6.3. 4.7 is shocking and very concerning as even in studies on children for his BSA the 50th percentile was above 5 but below 6.

The average you provided me was not even brought up by two cardiologists i have seen so i am very concerned now.

Do you rely on IVSd measurement by 2D or M mode more ? By 2D it was 0.53 and m mode 0.6

I was not looking for calculations and equation reference from a cardiologist here, i was looking for the experience of a cardiologist in his actual practice with children and whether it is common to see 0.5-0.6cm septum for children of my son's age and BSA and not just some estimated equation average which varies from study to study. Your statement that my child is quite a bit above average is really concerning.

doctor
Answered by Dr. Ilir Sharka 48 minutes later
Brief Answer:
Your son's values are quite normal.

Detailed Answer:
Hello again, dear XXXXXXX

I could explain that 4,75 mm is an average of the normal range, but a higher value than 5 or even 6 mm could still be normal as the range is a bit wide.

These are official values (chart values) at my institution.

It doesn't mean that different values from that are wrong, as it will depend from the children population these values are brought about. So these are not theoretical or literature values.

Regarding on the technical approach, 2D measurements are more reliable than M ones.

A 5 mm wall thickness is not an issue to be concerned about, as I said you at the beginning of our thread. It is within the normal values ranges for his body size.

So just relax and don't worry too much about it!

The most important issues is echo follow-up (as i said you before).

Sometimes echo values are prone to inter-observer and even intra-observer variability; and the value may slightly differ in the same child at the same time (4 or 5 or 6 mm).

Actually, I don't think any further medical study is necessary. If you are worried on the progression of ventricular wall thickness over time you may discuss with the attending doctor on the possibility of a cardiac MRI which would bring very accurate values in this regard.

Hope to have clarified your issues of concern!

In case of any further questions, feel free to ask me again.

Regards,

Dr. Iliri





Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 7 hours later
Thank you for the question. I saw a pediatric cardiologist and he did another echo and got 0.6cm on m mode and said it is perfectly normal and average for his age and BSA. He said we very rarely see someone of his age below 5.5, and his septum thickness matches the exact average.

I was wondering if you are a pediatric or adult cardiologist ?
doctor
Answered by Dr. Ilir Sharka 27 minutes later
Brief Answer:
My response to you:

Detailed Answer:
Hello again XXXX!

As I have mentioned you before, cardiac ultrasound may provide estimated values of cardiac dimensions, which may be slightly different from one examination to another, even when they are performed very close to each other.

This is because of the inter-observer variability, which is characteristic of cardiac ultrasound techniques.

I am sure that if you are going to check another echo by another pediatrician, it will yield a slightly different result each time, let's say 5.8; 5.2; or 5.9; etc..

Especially when following a M mode technique, the probability of having some errors is higher than on 2D measurements.

But, whichever of the above mentioned by you values is within the normal range.

THAT'S THE MOST IMPORTANT ISSUE.

No, returning to my levels of expertise, I would say you that I am adult cardiologist also trained on cardiac ultrasound.

Every doctor has its own experience and I try to give you some point of view from my daily practice.

There exists a wide range of inter-ventricular septum thickness and nevertheless, they are still considered normal.

Regards,

Dr. Iliri


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 4 days later
Hello doctor,

My brother recently went for his one year echo after they saw a sigmoid septum but no HCM.
I have attached a picture of his m mode measurements. His IVSd was 0.78cm and this new cardiologist saw the bulge and said he can't even call it a classic sigmoid septum and it is probably just an anomatical normal variant that is of no clinical significance. He also measures the bulge and it was 1cm and on some views even thinner. I attached a picture of the septum
With the bulge also.
However, i noticed after we left that his Ejection fraction was 76%, and last year it was 60%. I read usually this is in patients with HCM which my brother was cleared from. What would cause such a high EF ? My brother eats healthy, and although he smokes he works out in the gym everyday and has built muscles as well.
doctor
Answered by Dr. Ilir Sharka 16 hours later
Brief Answer:
I would explain as follows:

Detailed Answer:
Dear XXXXXXX

I reviewed the uploaded echo and I agree with his doctor's conclusions that these findings are within the normal ranges and there is no evidence with clinical relevant importance.

There exists no criteria on hypertrophic cardiomyopathy.

In addition, the second echo image (2D four chambers view) doesn't represent any characteristic pattern of sigmoid septum.

There is not any abnormal cardiac issues to be worried about.

The inter-ventricular septal thickness is quite normal and though the M mode estimation of left ventricular EF is a bit overestimated (judging from the M mode view), it is quite normal and doesn't confirm any criteria for HCM.

On my opinion, this EF variability (0.6 vs 0.76) is in fact a matter of echo measurement accuracy and has nothing to do with any evolving pathology.

Hope to have clarified your uncertainties!

Regards,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 2 hours later
Would ejection fraction normally be higher in people that maintain a healthy diet and work out?

I understand that most HCM patients that test positive for the gene have a reverse septum curve conex to the LV. Is it true that even in patients who are positive for the gene but don't have LVH, their normal septum would be abnormally in reverse curvature? Or is the reverse curvature caused by hypertroplphy only?
I came across one study only that mentioned those who are gene positive but negative for LVH and HCM they have subclinical HCM by a reverse curved septum by magnetic resource imaging. Has that been confirmed ?
doctor
Answered by Dr. Ilir Sharka 20 hours later
Brief Answer:
My opinion as follows:

Detailed Answer:
Dear XXXXXXX

Regarding your actual concerns, I would like to explain as follows:

Left ventricular ejection fraction (LVEF) is a general and the most frequently used marker of systolic cardiac performance in the daily practice.

It is true that apparently healthy individuals tend to have in general higher values of LVEF. But, in the meantime, it may result normal when some degree of diastolic dysfunction is measured during cardiac ultrasound (echo).

Furthermore, LVEF may result slightly different each time it is measured, and this is because there exists an accepted inter-observer and even intra-observer (the same examiner performs echo at different time intervals) variability.

In addition, the accuracy of LVEF will depend also on the applied technique utilized for its measurement.

But unaffected hearts have higher performance indexes (including LVEF) than the diseased hearts.

Now returning to the second point of interest, I would explain that there exists e broad variability when discussing about genetic reasons of hypertrophic cardiomyopathy.

In fact, there are more than hundred mutations from more than 30 identified responsible genes for sarcomeric structures. Other are actually being studied and discovered.

But, HCM is not caused only from sarcomeric structure defects; other reasons such as metabolic, storage and infiltrative diseases may be responsible.

So, it is difficult to confirm with certainty that a HCM phenotype will have always a positive gene test (sarcomeric structure mutations), although the presence of septum deformation (reverse curvature) is present.

This is the case in situations in some storage disease like Anderson-Fabry, Danon and Pompe, etc.

From the other side, not always when a gene test is positive, there will be a clinically measurable HCM phenotype or even microscopic sarcomeric disarrangement. This is because there exists variable genetic expression (penetrance).

So a direct and linear correlation between a positive gene test from one side and a reverse septal curvature, even a subclinical HCM doesn't exist.

But genetic testing adds value to etiologic diagnosis of HCM and even when screening relatives of a HCM patient.

When returning to the other question: Or is the reverse curvature caused by hypertrophy only?

I would reply: definitely not!

We actually are aware that a reverse curvature may be caused by other causes different from hypertrophy like right ventricle overload, altered aortic-ventricular geometric relationship that occur with aging and sclerosis.

Of course, there exist also intermediary patterns when the genetic defects are present, but we don't see hypertrophy or confirm HCM by echo.

In such cases, there exist variable degrees of sarcomeric disarrangements which may be detected by more sophisticated tests (like MRI) but it is difficult to predict which will develop hypertrophy of clinical HCM in the future years of life.

That's my point of view regarding these issues.

Hope to have definitely clarified your points of concern!

In case you will have future questions, you may ask me directly through my link on HealthcareMagic.

Kind regards,

Dr. Iliri




Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 12 minutes later
Thank you doctor for the detailed reponse.
So what i understood is that the reverse curavture may or may not be releated to the gene for HCM and there is no confirmed positive correlation. Correct ?

As you can see in the attached m mode measurement his systolic IVS was 1.8cm and by 2D doc said 1.5. Last year it was 1.3.
Is there any cause of concern for this increase although his IVS in diastole is 0.78cm lower than last year's measurement. For HCM, does systole IVS matter ? and would 1.8/1.5 be considered too high ? No reference range was given, but i found up to 2cm online.
Would the IVS in systole measurement affect Ejection fraction ?
doctor
Answered by Dr. Ilir Sharka 1 hour later
Brief Answer:
I would explain:

Detailed Answer:
Hello again!

You are right about the first conclusion.

Regarding the IVS thickness, I would explain to you that in fact there has been an overestimation of systolic IVS on the M-mode view by the examiner.

The measurement points have been placed a bit more distant than where they should be. That’s why the systolic thickness has resulted increased.

Although the M-mode measurements are prone of potential errors, they result within the normal ranges.

Nevertheless, the systolic thickness is not considered in the criteria of hypertrophic cardiomyopathy.

So relax as there is nothing to be worried about. No evidence of HCM may be concluded by the uploaded echo parameters.

LVEF may be affected by erroneously increasing systolic IVS thickness in M-mode.

Wishing you are having a nice day,

Regards,

Dr. Iliri

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 26 hours later
Thank you for the reassurance doctor.
One last question: my father (mid 50s) had ecg, echo and stress ecg. His stress ecg and echo were perfectly normal, but his ecg (not the stress one the normal resting one) mentioned minimal ST depression 0.025 mv.
What thay be a cause of concern ? And if not, what could have caused it since his streas ecg was normal ?
Is ST depression of this value commonly seen in healthy adults of his age or not ?
doctor
Answered by Dr. Ilir Sharka 5 hours later
Brief Answer:
Nothing to worry about!

Detailed Answer:
Dear XXXX!

Regarding your father's ECG, I would say that such a ST segment depression is not only clinically irrelevant, but it could hardly be caught by a normal eye.

In fact the normal ECG calibration is 1 mV equals 10 mm, so 0.025 mV denotes 0.25 mm.

Such tiny ST segment fluctuation may be normally seen even during blood pressure values fluctuation, blood glucose level fluctuation, with certain drugs use, from certain neurogenic factors, etc.

In general, it is not a matter of concern, as no clinical symtomatology is present or any medical tests result abnormal.

So, nothing to worry about!

Hope to have been helpful to you!

I remain at your disposal in case you have further questions in the future.

Best wishes,

Dr. Iliri


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Ilir Sharka

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