Basic echocardiography case studies
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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

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Basic Echocardiography Case Studies

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Basic echocardiography case studies

Basic EchocardiographyCase Studies

Wendy Blount, DVM

Nacogdoches TX


Basic echocardiography case studies

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


Basic echocardiography case studies

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


Basic echocardiography case studies

Trip

Differential Diagnoses

  • Aortic endocarditis

  • SAS with aortic regurgitation

  • Mitral regurgitation (endocarditis?)

    Diagnostic Plan

  • Thoracic radiographs

  • EKG

  • Echocardiography


Basic echocardiography case studies

Trip

EKG

  • Normal sinus rhythm for 10 minutes

    Thoracic Radiographs

  • Interstitial pattern caudal lung fields

  • Vertebral heart score 10.5


Trip echo

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 echo1

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 echo2

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 echo3

Trip - Echo

Long Axis – LVOT

  • Hyperechoic thickened mitral valve leaflets

    Diagnosis

  • Aortic endocarditis

    Therapeutic Plan

  • Elected euthanasia due to poor prognosis


Valvular endocarditis

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 endocarditis1

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 endocarditis2

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 endocarditis3

Valvular Endocarditis

Video


Maximus

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%


Maximus1

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


Maximus2

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)


Maximus3

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


Maximus4

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


Maximus5

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


Maximus6

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


Basic echocardiography case studies

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


Basic echocardiography case studies

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


Basic echocardiography case studies

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)


Basic echocardiography case studies

Ike

Diagnostics

  • Chest x-rays

    • Elevated trachea

    • Generalized cardiomegaly – VHS 9

    • Distended caudal vena cava

    • Hepatomegaly

    • Ascites


Basic echocardiography case studies

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


Basic echocardiography case studies

Ike

DDx Hypoalbuminemia

  • Liver disease

  • PLN

  • PLE unlikely with no clinical signs

  • Sequestration in ascites


Basic echocardiography case studies

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


Basic echocardiography case studies

Ike

Recheck Scheduled for 1 week

  • Echocardiogram

  • Electrolytes

  • Abdominal US

  • UPC

  • bile acids

  • Fluid analysis if ascites fails to resolve


Basic echocardiography case studies

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


Basic echocardiography case studies

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

Short Axis – LV Apex

  • Mild pericardial effusion

    Short Axis – LV PM

  • Mild pericardial effusion

  • LV subjectively thick

  • No evidence of pericardial hernia


Ike echo1

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 echo2

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 echo3

Ike - Echo

Short Axis – PA

  • Enlarged main pulmonary artery

  • RV enlarged

    Long Axis – 4 Chamber

  • No apparent enlargement of LA

  • LV thickened


Ike echo4

Ike - Echo

Long Axis – LVOT

  • No apparent enlargement of LA

  • LV thickened


Ike echo5

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 echo6

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

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 effusion1

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 effusion2

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 effusion3

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 effusion4

Pericardial Effusion

Video Pericardial Effusion

Video Pleural Effusion

Video Consolidated Lung Lobe

Video Normal thorax

Video Mediastinal Mass


Basic echocardiography case studies

Hank

Signalment

  • 10 week old male schnauzer

    Chief Complaint

  • Loud heart murmur heard on examination for routine vaccinations

  • Suspect congenital heart defect


Basic echocardiography case studies

Hank

Exam

  • mm pink, CRT 2 sec

  • 4/6 ejection murmur loudest at left heart base

  • Mild superficial pyoderma


Basic echocardiography case studies

Hank

Exam

  • mm pink, CRT 2 sec

  • 4/6 ejection murmur loudest at left heart base

  • Mild superficial pyoderma


Basic echocardiography case studies

Hank

Initial Differential Diagnoses

  • Pulmonic stenosis

  • Aortic Stenosis

    Initial Diagnostic Plan

  • Chest x-rays

  • EKG

  • Echocardiogram


Basic echocardiography case studies

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


Basic echocardiography case studies

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 echo1

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 echo2

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 echo3

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 echo4

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

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 stenosis1

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 stenosis2

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


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