basic echocardiography case studies wendy blount, dvm nacogdoches tx wendy blount, dvm nacogdoches...
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Basic EchocardiographyCase Studies
Basic EchocardiographyCase Studies
Wendy Blount, DVMNacogdoches TXWendy Blount, DVMNacogdoches TX
TripTrip
Signalment• 2 year old castrated male border collieChief 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
TripTrip
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
TripTrip
Differential Diagnoses• Aortic endocarditis• SAS with aortic regurgitation• Mitral regurgitation (endocarditis?)
Diagnostic Plan• Thoracic radiographs• EKG• Echocardiography
TripTrip
EKG• Normal sinus rhythm for 10 minutes
Thoracic Radiographs• Interstitial pattern caudal lung fields• Vertebral heart score 10.5
Trip - EchoTrip - 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 - EchoTrip - 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 - EchoTrip - 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 - EchoTrip - Echo
Long Axis – LVOT• Hyperechoic thickened mitral valve leaflets
Diagnosis• Aortic endocarditis
Therapeutic Plan• Elected euthanasia due to poor prognosis
Valvular EndocarditisValvular 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 EndocarditisValvular 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 EndocarditisValvular 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.
MaximusMaximus
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%
MaximusMaximus
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
MaximusMaximus
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)
MaximusMaximus
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
MaximusMaximus
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
MaximusMaximus
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
MaximusMaximus
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
IkeIke
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
IkeIke
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
IkeIke
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)
IkeIke
Diagnostics• Chest x-rays
– Elevated trachea – Generalized cardiomegaly – VHS 9– Distended caudal vena cava– Hepatomegaly– Ascites
IkeIke
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
IkeIke
DDx Hypoalbuminemia• Liver disease• PLN• PLE unlikely with no clinical signs• Sequestration in ascites
IkeIke
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
IkeIke
Recheck Scheduled for 1 week• Echocardiogram• Electrolytes• Abdominal US• UPC• bile acids• Fluid analysis if ascites fails to resolve
IkeIke
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
IkeIke
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 - EchoIke - Echo
Short Axis – LV Apex• Mild pericardial effusion
Short Axis – LV PM• Mild pericardial effusion• LV subjectively thick• No evidence of pericardial hernia
Ike - EchoIke - 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 - EchoIke - 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 - EchoIke - Echo
Short Axis – PA• Enlarged main pulmonary artery• RV enlarged
Long Axis – 4 Chamber• No apparent enlargement of LA• LV thickened
Ike - EchoIke - 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 - EchoIke - 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 EffusionPericardial 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 EffusionPericardial 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 EffusionPericardial 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 EffusionPericardial 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 EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
HankHank
Signalment• 10 week old male schnauzer
Chief Complaint• Loud heart murmur heard on examination for routine
vaccinations• Suspect congenital heart defect
HankHank
Exam• mm pink, CRT 2 sec• 4/6 ejection murmur loudest at left heart base• Mild superficial pyoderma
HankHank
Exam• mm pink, CRT 2 sec• 4/6 ejection murmur loudest at left heart base• Mild superficial pyoderma
HankHank
Initial Differential Diagnoses• Pulmonic stenosis• Aortic Stenosis
Initial Diagnostic Plan• Chest x-rays• EKG• Echocardiogram
HankHank
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
HankHank
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 - EchoHank - 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 - EchoHank - 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 - EchoHank - 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 - EchoHank - 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 - EchoHank - 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 StenosisPulmonic 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 StenosisPulmonic 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