basic echocardiography case studies
Download
Skip this Video
Download Presentation
Basic Echocardiography Case Studies

Loading in 2 Seconds...

play fullscreen
1 / 56

Basic Echocardiography Case Studies - PowerPoint PPT Presentation


  • 150 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Basic Echocardiography Case Studies' - remy


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
basic echocardiography case studies

Basic EchocardiographyCase Studies

Wendy Blount, DVM

Nacogdoches TX

slide2
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
slide3
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
slide4
Trip

Differential Diagnoses

  • Aortic endocarditis
  • SAS with aortic regurgitation
  • Mitral regurgitation (endocarditis?)

Diagnostic Plan

  • Thoracic radiographs
  • EKG
  • Echocardiography
slide5
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.
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

slide21
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
slide22
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
slide23
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)
slide24
Ike

Diagnostics

  • Chest x-rays
    • Elevated trachea
    • Generalized cardiomegaly – VHS 9
    • Distended caudal vena cava
    • Hepatomegaly
    • Ascites
slide25
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
slide26
Ike

DDx Hypoalbuminemia

  • Liver disease
  • PLN
  • PLE unlikely with no clinical signs
  • Sequestration in ascites
slide27
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
slide28
Ike

Recheck Scheduled for 1 week

  • Echocardiogram
  • Electrolytes
  • Abdominal US
  • UPC
  • bile acids
  • Fluid analysis if ascites fails to resolve
slide29
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
slide30
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

slide43
Hank

Signalment

  • 10 week old male schnauzer

Chief Complaint

  • Loud heart murmur heard on examination for routine vaccinations
  • Suspect congenital heart defect
slide44
Hank

Exam

  • mm pink, CRT 2 sec
  • 4/6 ejection murmur loudest at left heart base
  • Mild superficial pyoderma
slide45
Hank

Exam

  • mm pink, CRT 2 sec
  • 4/6 ejection murmur loudest at left heart base
  • Mild superficial pyoderma
slide46
Hank

Initial Differential Diagnoses

  • Pulmonic stenosis
  • Aortic Stenosis

Initial Diagnostic Plan

  • Chest x-rays
  • EKG
  • Echocardiogram
slide47
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
slide48
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
ad