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Basic Echocardiography Case Studies Wendy Blount, DVM Nacogdoches TX 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 • 3 murmurs: – To-and-fro murmur, 3/6, PMI left base – Holosystolic murmur 3/6 over rest of chest – 2/6 ejection murmur PMI Carotid • Bounding pulses, notable in small arteries • Precordial – exaggerated left apical heave • Lung sounds clear 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 Thoracic Radiographs • Interstitial pattern caudal lung fields • Vertebral heart score 10.5 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 – PA • No abnormalities noted Long Axis – 4 Chamber • LA appeared mildly enlarged • IVS bowed anteriorly toward RV • No evidence of mitral encodarditis or endocardiosis Trip - Echo Long Axis – LVOT • Hyperechoic thickened mitral valve leaflets Diagnosis • Aortic endocarditis Therapeutic Plan • Elected euthanasia due to poor prognosis 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 • Poor prognosis long term • Breed predisposition – Rottweiler, Boxer, Golden retriever – Newfoundland, German shepard 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 • Antibiotics – IV 3-5 days – broad spectrum until culture results – SC/IM 35 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. Valvular Endocarditis Video 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 Diagnostics • Thoracic Radiographs – Severe perihilar and interstitial edema – VHS 12.5 – Pulmonary lobar veins 2X arteries • EKG – – – – Normal sinus rhythm P wave 0.5 mV tall x 0.06 msec (tall and wide P wave) QRS complex tall 25-30 mV x 0.05 msec (LV enlargement) 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 • 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 – – – – – Elevated trachea 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 Short Axis – LV Apex • Mild pericardial effusion Short Axis – LV PM • Mild pericardial effusion • LV subjectively thick • No evidence of pericardial hernia Ike - Echo Short Axis – LV PM • IVSTD – 10.2 (n 3-6) • 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 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 Short Axis – PA • Enlarged main pulmonary artery • RV enlarged Long Axis – 4 Chamber • No apparent enlargement of LA • LV thickened 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 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, inrease 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 Pericardial Effusion Clinical Features • DDx – – – – – – Pericarditis Chronic CHF 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) – Careful not to confuse with liver in a peritineopericardial diaphragmatic hernia • Heart my 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 Pericardiocentsis 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 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 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 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 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 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 Diagnosis • Likely Pulmonic Stenosis • DDx RV thickening • Need Doppler to confirm, and to determine gradient • Cor triatriatum dexter Plan – updated • Referral to TAMU for ballon valvuloplasty • Atenolol 0.5 mg/kg PO BID (monitor weight to increased dose PRN until cath procedure) 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 ballon 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 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 Echocardiographic abnormalities • RV thickening • Post-stenotic dilitation of MPA • Pulmonic valve may be thickened with poor movement • Paradoxical septal motion may be noted in severe cases