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Practical Cardiology Case Studies Wendy Blount, DVM Nacogdoches TX Ginger Signalment • 12 year old SF cocker spaniel Chief complaint • Several episodes of collapse during the past month • Description matches partial seizure • Rear legs get weak on walks • Lethargic and dull in general Ginger Exam • Dark maroon oral mucous membranes • Rear foot pads cyanotic (heart sounds) • Split S2 • Neurologic exam normal, except dull mental status Ginger Differential Diagnosis – Split S2 • Pulmonic and aortic valves don’t close at the same time – Pulmonary hypertension – Normal variation in giant dogs – Reverse PDA Differential Diagnosis - cyanosis • Respiratory hypoxia • Cardiac hypoxia Ginger Initial Diagnostic Plan • CBC, GHP, electrolytes • Arterial blood gases, Pulse oximetry • ECG • Thoracic radiographs Bloodwork • Tech couldn’t get enough serum for serology • CBC – PCV 73% • GHP and electrolytes - normal Ginger DDx Differential Cyanosis • FATE – Femoral Artery ThromboEmbolism – Lack of femoral pulses – Feet cool to the touch • Right to Left shunt – ductus is distal to the brachiocephalic trunk – Reverse PDA – AV fistula with pulmonary hypertension – Tetralogy of Fallot Ginger Arterial blood gases • pO2 – 52 mmHg • pCO2 – 36 mmHg • all else normal Pulse oximetry • Lip – O2 sat 89% • Vulva - O2 sat 67% Ginger Ginger Ginger Thoracic radiographs • Normal great vessels • Normal heart size (VHS 9.5) • aortic bulge on VD • No evidence of severe respiratory disease which might cause hypoxia • No evidence of heart failure Ginger ECG • S wave mildly deep in leads I,, II, III, aVF • MEA 90o • Arrhythmia doesn’t seem likely Differential Diagnoses • Right to left shunt • Pulmonary hypertension Ginger Ginger ECG • S wave mildly deep in leads II, III, aVF • MEA 90o • Arrhythmia doesn’t seem likely Differential Diagnoses • Right to left shunt • Pulmonary hypertension Ginger Right to Left Shunt • Reverse PDA (right to left) – Eisenmeinger’s physiology • Tetralogy of Fallot • AV fistula with pulmonary hypertension Echocardiogram Ginger Right to Left Shunt • Reverse PDA (right to left) – Eisenmeinger’s physiology • Tetralogy of Fallot • AV fistula with pulmonary hypertension Echocardiogram Ginger Right to Left Shunt • Reverse PDA (right to left) – Eisenmeinger’s physiology • Tetralogy of Fallot • AV fistula with pulmonary hypertension Echocardiogram Ginger Right to Left Shunt • Reverse PDA (right to left) • Tetralogy of Fallot • AV fistula with pulmonary hypertension Echocardiogram • RV thickening • RV normally thinner than LV • No PDA seen without Doppler Ginger Bubble Study • Place venous catheter • Shake 5-10 cc saline vigorously • Place US probe where you can look for shunting – Long 4 chamber view – Abdominal aorta • Inject IV quickly • Bubbles normally appear on the right (video) • Watch for bubbles on the left (this means R to L shunt) • False negatives when bubbles disperse quickly Reverse PDA • Reverse PDAs are usually large, providing no resistance to blood flow – Ductus is often as large in diameter as the great vessels it connects • increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time • a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week • Often do well until polycythemia develops late in life Reverse PDA Treatment • Ligation of right to left shunting PDA results in death due to pulmonary hypertension – Has been ligated in stages without causing death – Cyanosis and symptoms usually persist • Managed Medically by periodic phlebotomy – – – – – Remove 10 ml/lb and replace with IV fluids Eliminate hyperviscosity without inducing hypoxia Goal for PCV is 60-65% Excellent blood for RBC transfusion ;-) Repeat when clinical signs return Reverse PDA Treatment • Hydroxyurea – 30 mg/kg/day for 7 to 10 days followed by 15 mg/kg/day. – CBC q1-2 weeks – D/C when Bone marrow suppression – Resume lower dose – Some dogs require higher doses – side effects – GI and sloughing of the nails Reverse PDA Prognosis • Can do well short term • Poor prognosis long term – Survival months to a year or two • Phlebotomy interval is progressively shorter Gabby 6 month female DSH Presented for OHE PreAnesthetic Exam HR 100 • No other abnormal findings • Preanesthetic bloodwork normal Gabby Pre-Anesthetic ECG 20mm = 1 mV 25 mm/sec • Heart rate – P rate is 160 bpm, QRS rate is 100 bpm • Rhythm 3rd Degree AV block – no consistent PR interval – P and QRS complexes are disassociated, but each regular Gabby • Gabby was not spayed at 6 months of age • When she reached 7 years of age, she had her 4th litter • She was referred to Drs. Miller and Gordon at TAMU for spay – When induced, her heart rate immediately fell to 40 and was progressively dropping – A temporary pacemaker was placed – Gabby was spayed and recovered uneventfully – Gabby turned 17 years old in 2010, and has since passed on Gabby Dear Doc, Because you took away my favorite pastime, I have turned to a life of substance abuse. It’s your fault. Love, Gabby 3rd degree AV block 3rd Degree AV block is the most common cause of bradycardia in the cat Treatment- cats • Often no treatment needed for cats – AV node pacemaker is 100 per minute – AV node pacemaker is 40-60 per minute in the dog • Cats do well unless they undergo anesthesia • Avoid drugs that increase vagal tone – Alpha blockers – Dexdomitor, Rompun 3rd degree AV block in Dogs • • • • Usually presents for syncope (HR 20-40 per minute) “Cannon wave” jugular pulses (bradycardia) Treated with pacemaker implantation Drug therapy not usually successful – Usually no response to atropine – Atropine often makes 2nd degree block go away – Some have tried theophylline • Prognosis poor without pacemaker • If lactate is high, emergency pacemaker is needed 3rd degree AV block in Dogs Pre-Operative ECG • Atrial rate = 200 per minute • Ventricular rate = 40 per minute 50 mm/sec 3rd degree AV block in Dogs Post-Operative ECG • Ventricular rate = 100 50 mm/sec Trip Signalment • 2 year old castrated male border collie Chief Complaint/History • Productive Cough, weight loss for 2 months • Breathing hard for a 2 days • Energy good; did well in agility 4 days ago • Owner thinks has had lifelong PU-PD • Has wanted to be in AC this summer – unlike last summer when he enjoyed being outside Trip Exam • T 102.2, P 168, R 42, CRT 3 sec • BCS 2.5 • BP 100 • Bounding pulses, notable in dorsal pedal artery • Precordial – exaggerated left apical heave • Lung sounds clear Trip Exam • 3 murmurs: 1. PMI left base – To-and-fro murmur 3/6 – aortic stenosis in systole, regurg in diastole 2. PMI left apex, but heard all over chest – Holosystolic murmur 3/6 – Mitral regurgitation due to LHF 3. PMI Carotid artery – 2/6 ejection murmur – aortic stenosis Trip Differential Diagnoses • Aortic endocarditis • SAS with aortic regurgitation • Mitral regurgitation (endocarditis?) Diagnostic Plan • Thoracic radiographs • EKG • Echocardiography Trip EKG • Normal sinus rhythm for 10 minutes Trip EKG • Normal sinus rhythm for 10 minutes Trip EKG • Normal sinus rhythm for 10 minutes Thoracic Radiographs • Interstitial pattern caudal lung fields • Vertebral heart score 10.5 • Enlarged cranial pulmonary lobar vein • Mildly enlarged left atrium • Early left congestive heart failure Trip - Echo Short Axis – LV Apex • No abnormalities noted Short Axis – LV PM Trip - Echo Short Axis – LV Apex • No abnormalities noted Short Axis – LV PM Trip - Echo Short Axis – LV Apex • No abnormalities noted Short Axis – LV PM • LVIDD – 57.3 (n 31.3-34) • IVSTS – 15.5 mm (n 12.6-13.7) • LVIDS – 41.1 mm (18.8-20.7) • FS = (57.3-41.1)/57.3 = 28% (n 30-46%) • EF = 54% (n >70%) Trip - Echo Short Axis – MV • EPSS – 8 mm (n 0-6) Short Axis – Ao/RVOT • AoS – 20.2 (normal) • LAD – 27.8 (n 19.0-20.5) • LA/Ao – 27.8/20.2 = 1.38 (n 0.8-1.3) • Aortic valve leaflets are hyperechoic Trip - Echo Short Axis – MV • EPSS – 8 mm (n 0-6) Short Axis – Ao/RVOT • AoS – 20.2 (normal) • LAD – 27.8 (n 19.0-20.5) • LA/Ao – 27.8/20.2 = 1.38 (n 0.8-1.3) • Aortic valve leaflets are hyperechoic Trip - Echo Short Axis – MV • EPSS – 8 mm (n 0-6) Short Axis – Ao/RVOT • AoS – 20.2 (normal) • LAD – 27.8 (n 19.0-20.5) • LA/Ao – 27.8/20.2 = 1.38 (n 0.8-1.3) • Aortic valve leaflets are hyperechoic Trip - Echo Short Axis – PA • No abnormalities noted Long Axis – 4 Chamber Trip - Echo Short Axis – PA • No abnormalities noted Long Axis – 4 Chamber Trip - Echo Short Axis – PA • No abnormalities noted Long Axis – 4 Chamber • LA appeared mildly enlarged • IVS bowed anteriorly toward RV • No evidence of mitral encodarditis or endocardiosis • Vegetation on aortic valve Trip - Echo Trip - Echo Long Axis – LVOT (video) • Hyperechoic thickened mitral valve leaflets Diagnosis • Aortic endocarditis Therapeutic Plan • Elected euthanasia due to poor prognosis Trip Valvular Endocarditis Clinical Features • Present for FUO, weight loss or heart failure • Aortic much more common than mitral • Dogs much more common than cats • Many bacteria including Bartonella • Breed predisposition – Rottweiler, Boxer, Golden retriever – Newfoundland, German shepard Valvular Endocarditis Clinical Features • Abnormal valve + bacteremia = endocarditis • Bacteremia caused routinely by: – – – – – – Dental cleaning Brushing your teeth (chewing) Constipation, any GI illness defecation Urinary catheterization infection Valvular Endocarditis ECG abnormalities • Tall, wide P wave (LA enlargement) • Tall R wave (LV enlargement) • Ventricular arrhythmias common – Treat if multiform of >30 per minute – Class I or III antiarrhythmic – Sotalol 2-3 mg/kg PO BID Thoracic radiographs • Left heart failure Valvular Endocarditis ECG abnormalities • Tall, wide P wave (LA enlargement) • Tall R wave (LV enlargement) • Ventricular arrhythmias common – Treat if multiform of >30 per minute – Class I or III antiarrhythmic – Sotalol 2-3 mg/kg PO BID Thoracic radiographs • Left heart failure Valvular Endocarditis Echocardiographic abnormalities • Thickened, hyperechoic valves • Vegetation may flop around – MV in diastole, AV in systole • Variable LV dilation (more with time) • FS normal to low normal until myocardial failure • MV endocarditis can be difficult to distinguish from MV endocardiosis – Endocarditis dogs are systemically ill Valvular Endocarditis Treatment • Based on urine and blood culture and sensitivity, Bartonella PCR • Antibiotics – IV 3-5 days – broad spectrum until culture results – SC/IM 3-5 days – Then PO long term – often for life • Treat Heart failure (severe) • Treat ventricular arrhythmia if present • Watch for and treat bacterial embolization of abdominal organs, skin, IVDiscs, CNS, joints, etc. • Watch for and treat immune complex disease Valvular Endocarditis Prognosis • <20% survival • Antibiotic therapy often required for life • Median survival is 6 days from diagnosis for aortic endocarditis • Survival is longer for mitral endocarditis – LHF due to MR not as severe as AoR (Client Handout) Maximus 18 month old male Boxer Chief Complaint • Drastic and rapid weight loss • Not eating well • Coughing up blood tinged fluid since yesterday Exam, Chest rads, ECG • Similar to Trip, except temp 103.8 • And BCS 2 Maximus Diagnostics • Blood culture – negative (2 samples 2 hours apart) • Urine culture – Enterobacter susceptible to all • CBC – neutrophilia 23,100/ul – Mild anemia – PCV 35.5% Maximus Diagnostics • General Health Profile, electrolytes – BUN – 55 (n 10-29) – ALT – 225 (n 10-120) – Albumin – 2.2 (n 2.3-3.7) • Urinalysis – USG – 1.045 – WBC 7-10/hpf, rare bacteria seen Maximus Treatment (58 lbs, BCS 2, RR 66) • Antibiotics – IV - ampicillin 750 mg TID, Baytril 150 mg BID x 3 days – IM – ampicillin 750 mg BID, Baytril 150 mg x 3 days – PO – ampicillin 750 mg BID, Baytril 136 mg PO for life • Furosemide – 100 mg IV TID the first day - RR down to 28 – Then 75 mg PO BID • Enalapril – 15 mg PO BID Maximus Treatment – Day 3 – RR 30, eating well • Chest x-rays – Pulmonary edema much improved, but mild amount still present • Furosemide - 75 mg PO BID • Enalapril – 15 mg PO BID • Added Spironolactone – 25 mg PO BID Maximus Diagnostics – Day 5 – RR 36, BP 150 • Chest x-rays - No change • BUN – 43 • Electrolytes - normal Treatment – Day 5 • Furosemide - 75 mg PO BID • Enalapril – 15 mg PO BID • Spironolactone – increased to 50 mg PO BID • Added Hydralazine – 12.5 mg PO BID Maximus Diagnostics – Day 10 RR 30, BP 135, Wt 61.8, Temp 103 • Chest x-rays – perihilar edema resolved • BUN – 11, albumin 2.3 • Electrolytes – normal • CBC – neutrophilia 23,000/ul Continued this treatment for the rest of Max’s life – 3 months Ike Signalment • 7 year old castrated male Persian cat Chief Complaint • Recurring anemia • Episodes of weakness, anorexia, dullness and salivation • Constipation often associated with episodes • Tremendous hair loss and 2 lb weight loss over 6 months Ike Exam – T 100.3, P 180, R 40, BP 135 • Fleas++++ • Gallop rhythm, followed by normal heart sounds, followed by 2/6 systolic murmur • Hepatomegaly and mild to moderate ascites • Jugular vein distension • Did not do hepatojugular reflux test • Tongue protrudes and tip is dry • Breathes with mouth open when stressed Ike Diagnostics • CBC – normal • FeLV/FIV – negative • GHP/electrolytes – – – – – ALT – 218 (n 10-100) Bili – 0.3 (high normal) Albumin 1.7 (n 2.3-3.4) K – 2.5 (n 2.9-4.2) Ike Diagnostics • Chest x-rays Ike Diagnostics • Chest x-rays Ike Diagnostics • Chest x-rays – – – – – Elevated trachea (heart enlargement) Generalized cardiomegaly – VHS 9 Distended caudal vena cava Hepatomegaly Ascites Ike Diagnostics • Diagnosis - Right heart failure with cardiomegaly • DDx – cardiomegaly – Diaphragmatic hernia – pericardial effusion – heart enlargement • HCM, DCM, RCM • VSD • Valvular disease – Hypoalbuminemia/liver disease may be contributing to ascites Ike DDx Hypoalbuminemia • Liver disease • PLN • PLE unlikely with no clinical signs • Sequestration in ascites Ike Initial Treatment • No echo done because Ike became dyspneic after chest rads • Furosemide 5 mg PO BID (wt 5 lbs 7 oz) • Potassium gluconate 2 mEq PO SID • Metronidazole 625 mg PO SID x 2 weeks Ike Recheck Scheduled for 1 week • Echocardiogram • Electrolytes • Abdominal US • UPC • bile acids • Fluid analysis if ascites fails to resolve Ike Recheck – 1 week - Exam • Ike tremendously improved • Weight gain of 5 ounces • Ascites has resolved • Hepatomegaly no longer present • P 160, RR 28, BP 110 • Haircoat seems improved • 2/6 systolic murmur loudest at the sternum • No open mouth breathing or inc RR when stressed Ike Recheck – 1 week - Diagnostics • Electrolytes – K 2.7 • Albumin - 2.4 (normal) • ALT - 134 (n 10-100) • Bili - 0.3 • UPC – 0.5 • Bile Acids (fasting) - 157 Ike - Echo Ike - Echo Ike - Echo Short Axis – LV Apex • Mild pericardial effusion Short Axis – LV PM • Mild pericardial effusion • LV subjectively thick • Papillary muscles really big • No evidence of pericardial hernia Ike - Echo Short Axis – LV PM Dx – Hypertrophic • IVSTD – 10.2 (n 3-6) Cardiomyopathy • LVIDD – 14.1 (n 10-21) • LVPWD – 6.95 (n 3-6) • IVSTS – 14.85 (4-9) • LVIDS – 3.5 (n 4-10) • LVPWS – 9.6 (n 4-11) • FS – (14.1-3.5)/14.1 = 74.5% EF = 98% Ike - Echo Ike - Echo Short Axis – LV MV • EPSS – 2 mm Short Axis – LA/RVOT Ike - Echo Short Axis – LV MV • EPSS – 2 mm Short Axis – LA/RVOT Ike - Echo Short Axis – LV MV • EPSS – 2 mm Short Axis – LA/RVOT • RVOT looks subjectively enlarged • LA and LA normal • LA/Ao = 11.1/8.8 = 1.26 (normal) Ike - Echo Ike - Echo Ike - Echo Short Axis – PA • Enlarged main pulmonary artery • RV enlarged Long Axis – 4 Chamber • No apparent enlargement of LA • LV thickened Ike - Echo Ike - Echo Long Axis – LVOT • No apparent enlargement of LA • LV thickened Ike - Echo Abdominal US • No fluid present in the abdomen • Main bile duct tortuous • Pancreas normal • Did not do liver aspirate because Ike would not tolerate it without general anesthesia Ike - Echo Abdominal US • No fluid present in the abdomen • Main bile duct tortuous • Pancreas normal • Did not do liver aspirate because Ike would not tolerate it without general anesthesia Ike - Echo Assessment • Hypertrophic Cardiomyopathy – Biventricular failure – Secondary pericardial effusion, ascites, hepatomegaly • Enlarged Pulmonary artery of unknown cause (DDx) – Heartworm disease – Pulmonary hypertension • Liver Dysfunction of unknown cause – Probable history of pancreatitis – Possibly contributed to by passive congestion of RHF • Financial Resources for Ike’s Diagnosis and Treatment have been depleted Ike - Echo Treatment - Update • Finish metronidazole, then start milk thistle • Increase Kgluconate to 2 mEq PO BID • Continue furosemide 5 mg PO BID • Add enalapril 1.25 mg PO SID – Recheck BUN/lytes 5 days – If OK, increase to BID – Recheck BUN/lytes 5 days • Laxatone PRN for constipation • Recheck echo, chest rads in 6 months or sooner if RR > 40 at rest • Ike died acutely just prior to his 6 month recheck Pericardial Effusion Clinical Features • DDx – – – – – – Pericarditis Chronic CHF (usually RHF) Blood – left atrial tear, HSA, coagulopathy Pericardial cyst Idiopathic 50% are neoplasia – carefully look at RA • ECG – electrical alternans Pericardial Effusion Echocardiographic Abnormalities • Careful not to confuse pericardial fat with pericardial effusion – Look at relative echogenicity • Careful not to confuse normal anechoic structures with pericardial effusion – Descending aorta – Enlarged left auricle Pericardial Effusion Echocardiographic Abnormalities • Careful to distinguish pericardial from pleural effusion – Pericardium not visualized with pleural effusion – Collapsed lung lobes may be seen with pleural effusion (look like liver in US) – Careful not to confuse consolidated lung with liver in a peritineopericardial diaphragmatic hernia • Heart may swing back & forth in the pericardium Pericardial Effusion Echocardiographic Abnormalities • Cardiac tamponade – – – – – Compression of RV Diastolic collapse of RV IVS may be flattened with paradoxical motion Pericardiocentesis is imperative Aggressive diuresis will reduce preload • Evaluation of heart base tumor prior to pericardiocentesis will be more thorough Pericardial Effusion Video Pericardial Effusion Video Pleural Effusion Video Consolidated Lung Lobe Video Normal thorax Video Mediastinal Mass Taz Signalment • 7 year old neutered male sharpei • Annual vaccines 2 weeks ago Chief Complaint • Hasn’t felt good since vaccines • Breathing really hard • Belly is swelling • Not eating Taz Exam – RR 77, mm pale, CRT 4 sec • Positive hepatojugular reflux • Ascites • Peripheral edema – ventral legs and ventral abdomen • Muffled heart sounds CBC, panel, lytes, heartworm test • No abnormalities noted Taz Taz Taz Echocardiogram • Pronounced pericardial effusion with cardiac tamponade • Pericardiocentesis – 1 L fluid that resembles blood – Does not clot after 20 minutes – PCV 38%, cytology non-septic exudate (hypersegmented neutrophils) • IV fluid bolus 500 ml • Echo measurements after tap normal PT, PTT, ACT • normal Taz Abdominal US • Normal Sent pericardial fluid for culture and sensitivity Emergency Referral to TAMU for Echocardiogram • Taz was VERY painful on the ride to Bryan • Small amount of pericardial effusion – not enough to tap • No cardiac masses detected • Abdominal ultrasound NSAF • Discharged with no medications, to recheck in one week Taz Recheck 1 week • Taz doing exceptionally well • No growth on culture and sensitivity • Signs of right heart failure have resolved • No ascites, dyspnea, peripheral edema, jugular distension • Abdominal palpation normal • • • • • Chest x-rays show VHS 11 Echo shows 2 cm pericardial effusion Tapped again and dispensed pain meds Rx doxycycline 10 mg/kg PO BID x 3 weeks Rx prednisone 0.5 mg/kg PO SID x 2 weeks, then QOD Taz Recheck 30 days • Exam, chest rads and echo are normal • Taper off prednisone over the next 30 days • Taz has had no recurrence of pericardial effusion in the past 6 years Cardiac Masses DDx • Chemodectoma • HSA • Myxosarcoma • Ectopic thyroid carcinoma • Mesothelioma • LSA • fibrosarcoma Cardiac Masses Echocardiographic Features • Usually at the heart base or in the RA • Careful not to confuse with – Epicardial fat (especially on the AV groove when there is pericardial effusion) – Trabeculae on the right auricle when floating in pericardial effusion Hank Signalment • 10 week old male schnauzer Chief Complaint • Loud heart murmur heard on examination for routine vaccinations • Suspect congenital heart defect Hank Exam • mm pink, CRT 2 sec • 4/6 ejection murmur loudest at left heart base • Mild superficial pyoderma Hank Initial Differential Diagnoses • Pulmonic stenosis • Aortic Stenosis Initial Diagnostic Plan • Chest x-rays • EKG • Echocardiogram Hank Hank Hank Thoracic radiographs • Dorsally elevated trachea • Vertebral heart score 9.5 • Right heart enlargement • Right auricular/atrial enlargement • Distended caudal vena cava • Bulge at main pulmonary artery Hank EKG • Tall P waves (0.5-0.6 mV) • RA enlargement • Deep S waves in leads I, II and III (-13 to -15 mV) • RV enlargement • Tachycardia 200-210 bpm • Under Buprenex-ace sedation Hank - Echo Hank - Echo Short Axis – LV Apex • RV seems thickened Short Axis – LV PM, MV, Ao/RVOT • RV as thick as LV – markedly thickened • IVS is flattened Hank - Echo Hank - Echo Short Axis – PA • MPA dilated • RV as thick as LV – markedly thickened Long Axis – 4 Chamber • Aberrant septum dividing RA into 2 chambers – cranial and caudal Long Axis – LVOT • RV as thick as LV – markedly thickened Hank - Echo Hank - Echo Diagnosis • Likely Pulmonic Stenosis • DDx RV thickening – Heartworms impossible in a 10 week old puppy – Pulmonary hypertension rare in a 10 week old puppy • Need Doppler to confirm, and to determine gradient • Cor triatriatum dexter Hank - Echo Plan – updated • Referral to TAMU for balloon valvuloplasty • Atenolol 0.5 mg/kg PO BID (monitor weight to increased dose PRN until cath procedure) Pulmonic Stenosis Clinical features • Many breed predispositions – Bulldog, chihuahua, Beagle, Cavalier • Often valvular and subvalvular • Valvular defect can be corrected by valvuloplasty • Prognosis varies, depending on severity – Mild – less than 50 mm Hg gradient – Moderate – 50-100 mm Hg – Severe - >100 mm Hg • Can be progressive Pulmonic Stenosis Clinical features • Bulldogs and Boxers can have left coronary artery anomaly, which can preclude balloon valvuloplasty • Arrhythmia is much more common than RHF • May be part of Tetralogy of Fallot – – – – PS RV hypertrophy VSD Overriding aorta Pulmonic Stenosis Coronary Artery Anomaly • Instead of R and L coronary aa, there is a single coronary a. • It splits and the left branch encircles the pulmonary a. • It can be ruptured if the PS is ballooned • These dogs may have normal PV and functional PS due to this anomaly Pulmonic Stenosis Echocardiographic abnormalities • RV thickening • Post-stenotic dilatation of MPA • Pulmonic valve may be thickened with poor movement • Paradoxical septal motion may be noted in severe cases • Tricuspid dysplasia is a common concurrent malformation – RHF is rare in dogs with PS alone – Many PS dogs that develop RHF also have tricuspid dysplasia (Client Handout)