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Basic Echocardiography Case Studies

Basic Echocardiography Case Studies. Wendy Blount, DVM Nacogdoches TX. Jake. Signalment 9 year old male Boxer Chief Complaint Deep cough when walking in the morning, for about one week Appetite is good. Jake. Exam Weight 81.9 – has lost 5 pounds in 3 months (BCS 3) Temp 101.4

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Basic Echocardiography Case Studies

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  1. Basic EchocardiographyCase Studies Wendy Blount, DVM Nacogdoches TX

  2. Jake Signalment • 9 year old male Boxer Chief Complaint • Deep cough when walking in the morning, for about one week • Appetite is good

  3. Jake Exam • Weight 81.9 – has lost 5 pounds in 3 months (BCS 3) • Temp 101.4 • Mucous membranes pink, CRT 3.5 seconds • Subtle dependent edema on the lower legs • Jugular veins normal • Harsh lung sounds • 3/6 holosystolic murmur, PMI left apex • Heart rate 160 per minute • Respirations 55 per minute • Femoral pulses somewhat weak

  4. Jake Differential Diagnosis - Cough • Respiratory Disease • Cardiovascular Disease • Both

  5. Jake Diagnostic Plan (B Client) • Blood Pressure • 150 mm Hg systolic (Doppler) • Chest X-rays • Massively enlarged heart (VHS 12.5) • Enlarged LA, LV (dorsally elevated trachea) • Enlarged pulmonary veins • Perihilar pulmonary edema • Left congestive heart failure

  6. Jake Immediate Therapeutic Plan (10 am) • Furosemide • 80 mg IM • 4 hours later • Respiratory rate is 36 per minute

  7. Jake Diagnostic Plan – 2nd Wave (2 pm) • EKG • Normal Sinus Rhythm • Echocardiogram

  8. Jake - Echo Transverse - LV Apex • LV Looks Big Transverse - LV Papillary Muscles • LV looks REALLY big • Myocardium is hardly moving • Flat papillary muscles

  9. Jake - Echo Transverse - LV Papillary Muscles • IVSTD – 9.7 mm (n 10.8-12.3) • LVIDD – 72.1 mm (n 43-48) • LVPWD – 15.1 mm (n 8.7-10) • IVSTS – 11.9 mm (n 16.5-18.1) • LVIDS – 67.1 mm (n 27.4-30.4) • LVPWS – 13.0 mm (n 14-15.6) FS = LVIDD – LVIDS LVIDD (72.1-67.1)/72.1 = 7% (n 30-46%) EF = 15% (n >70%)

  10. Jake - Echo Transverse - Mitral Valve • No increased thickness of MV • No vegetations on the MV • EPSS – 12 mm (n <6 mm) Transverse – Aortic Valve/RVOT • LA at least Double Big

  11. Jake - Echo Transverse - Aortic Valve/RVOT • AoS – 23.1 mm (n 27.4-30.4) • LAD – 44.7 mm (n 25.8-28.4) • LA:Ao = 44.7/23.1 = 1.9 (n 0.8-1.3) Transverse – Pulmonary Artery • No abnormalities noted

  12. Jake - Echo Long – 4 Chamber • LV massively enlarged • Poor systolic function • LA 2x enlarged • IVS is bowed toward the right, due to LV dilation Long – LVOT • No abnormalities in LVOT

  13. Jake – Dx & Tx Recommendations • Left Congestive Heart Failure • Mini-panel and electroytes • Furosemide 80 mg PO BID • Enalapril 20 mg PO BID • Recheck mini-panel and electrolytes in 3-5 days • Recheck chest rads 3-5 days • Dilated Cardiomyopathy • Pimobendan 10 mg PO BID (declined) • Carnitine 2 g PO BID • Recheck echo, chest rads, EKG, mini-panel/lytes 60 days (sooner if respiratory rate >40 at rest)

  14. Jake - Bloodwork CBC • normal Mini-panel - BUN, creat, glucose, TP, SAP, ALT • Normal Electrolytes • Not done

  15. Jake – Follow-Up Recheck – 6 days • BUN 30 (n 10-29) • Creat normal • Electrolytes not done • Chest x-rays not done 60 day Recheck - Pending

  16. Dilated Cardiomyopathy Common Echocardiographic Lesions • Dilation of all 4 heart chambers • Large LVIDD (eventually large LVIDS also) • Hypokinesis of LV wall and IVS • Reduced FS • Paradoxical septal motion • Increased EPSS • Normal looking MV and TV leaflets • Papillary muscle flattening

  17. Dilated Cardiomyopathy Video

  18. Pocket Signalment • 13 year old spayed female yorkie (5 pounds) Chief Complaint • Harsh cough several times daily for 2 months • History of chronic inflammatory liver disease, luxating patellas, chronic periodontal disease and multiple allergies; these problems clinically doing well at this time. • Mammary carcinoma removed one year previously, at the time of OHE.

  19. Pocket Exam • Temp 100.3, P 110, R 26, BP 110, BCS 3.5 • BAR, well hydrated, in good body condition • Crackles in the small airways, especially at peak inspiration • Pronounced respiratory sinus arrhythmia • Normal heart sounds • Pulses normal, CRT < 2 sec • Mature cataract right eye

  20. Pocket Differential Diagnoses - Cough • Chronic Bronchitis • Collapsing trachea Diagnostic Plan - initial • Chest and cervical x-rays • Inspiratory - VD and right lateral • Expiratory - left lateral

  21. Pocket Thoracic and cervical radiographs • No collapse of the trachea • Vertebral heart score 10 • Normal cardiac silhouette and pulmonary vasculature • Pronounced peribronchiolar pattern • Shoulder arthritis • Vertebral arthritis • Normal sized liver

  22. Pocket Diagnostics – 2nd round • Transtracheal wash • Cytology – suppurative inflammation (mature neutrophils) • Culture negative Treatment – Diagnosis Chronic Bronchitis • Hydrocodone as needed for cough suppression • Inhaled steroids PRN for cough

  23. Daisy Signalment • 15 year old spayed female mixed terrier • 11 pounds Chief Complaint • Became dyspneic while on vacation, as they drove over a mountain pass • Come to think of it, she has been breathing hard at night for some time

  24. Daisy Exam • T 100.2, P 185, R – 66, BP – 145, BCS – 3.5 • Increased respiratory effort • 3/6 holosystolic murmur loudest at left apex • Mucous membranes pale pink • Crackles in the small airways • Pulses weak • CRT 3.5-4 seconds

  25. Daisy Differential Diagnosis - Dyspnea • Suspect congestive heart failure • Suspect mitral regurgitation • Concurrent respiratory disease can not be ruled out Initial Diagnostic Plan • Chest x-rays • CBC, mini-panel, electrolytes

  26. Daisy CBC, mini-panel, electrolytes • Normal Thoracic radiographs • Markedly enlarged LA • Compressed left mainstem bronchus • Perihilar edema • Vertebral heart score 11.75 • Elevated trachea – LV enlargement • Right heart enlargement

  27. Daisy Initial Therapeutic Plan • Lasix 25 mg IM, then 12.5 mg PO BID • Enalapril 2.5 mg PO BID • Owner is a lab tech, and set up oxygen mask to use PRN at home • Recheck BUN, potassium, chest rads 3-5 days • Come back sooner if respiratory rate at rest is above 40 per minute without oxygen

  28. Daisy Recheck – 4 days • Daisy’s breathing is much improved (30-40 at rest) • Lateral chest x-ray • Electrolytes normal • BUN 52

  29. Daisy Diagnostic Plan - updated • Decrease enalapril to SID • Recheck BUN 1 week • Recheck chest rads 1 week Recheck – 1 week • BUN – 37 • Thoracic rads no change • Request recheck in 3 months, or sooner if respiratory rate at rest is above 40 per minute

  30. Daisy 2 months later • Daisy is breathing hard again at night Exam • Same as initial presentation Diagnostic Plan • CBC, mini-panel, electrolytes • Chest x-rays

  31. Daisy Bloodwork • CBC, electrolytes normal • BUN 88 Therapeutic Plan • Increase furosemide to 18.75 mg PO BID • Add hydralazine 2.5 mg PO BID • Recheck chest rads, BUN, electrolytes, blood pressure 1 week

  32. Daisy Recheck – 1 week • Clinically much improved – respiratory rate 30-40 per minute at rest • electrolytes normal • BUN 58 • Blood pressure 135 • Chest x-rays • Recommend recheck in 3 months, or sooner if respiratory rate above 40 per minute at rest

  33. Daisy Recheck – 6 months • Daisy dyspneic again Exam • Similar to last crisis – BP 90 Diagnostic Plan • CBC, mini-panel, electrolytes, chest x-rays • Echocardiogram

  34. Daisy Bloodwork • CBC, electrolytes normal • BUN 105, creat 2.1 Chest x-rays • Similar to last crisis

  35. Daisy - Echo Short Axis – LV apex • LV looks big Short Axis – LV papillary muscles • IVSTD – 6.0 mm – low normal • LVIDD – 35 mm (n 20.2-25) • LVPWD – 4.3 mm – low normal • IVSTS – 9.4 mm – normal • LVIDS – 25 mm (n 11.1-14.6) • LVPWS – 8.4 mm - normal

  36. Daisy - Echo Short Axis – LV papillary muscles • IVSTD – 6.0 mm – low normal • LVIDD – 35 mm (n 20.2-25) • LVPWD – 4.3 mm – low normal • IVSTS – 9.4 mm – normal • LVIDS – 25 mm (n 11.1-14.6) • LVPWS – 8.4 mm – normal • FS – (35-25)/35 = 29% (normal 30-46%)

  37. Daisy - Echo Short Axis - MV • MV leaflets hyperechoic and thickened • EPSS – 8 mm (n 0-6) Short Axis – Aortic Valve/RVOT • LA appears 2-3x normal size • AoS – 13.0 – normal • LAD – 33 mm (n 12.8-15.6) • LA/Ao = 2.5 (n 0.8-1.3)

  38. Daisy - Echo Long View – 4 Chamber • LV and LA both appear large • MV is very thick and knobby, with some prolapse into the LA Long View – LVOT • Large LA, Large LV

  39. Daisy - Echo Therapeutic Plan • Increase hydralazine to 5 mg PO BID • Add spironolactone 12.5 mg PO BID • Add pimobendan 1.25 mg PO BID • Increase furosemide to 18.75 mg PO TID x 2 days, then decrease to BID if respiratory rate decreases to less than 40 per minute at rest. • Recheck 1 week – BUN, creat, phos, electrolytes, chest rads, BP

  40. Daisy - Echo Recheck – 1 week • Clinically improved again • BP - 125 • BUN 132, creat 2.6, phos 6.6 • Electrolytes normal • chest rads improved pulmonary edema Therapeutic Plan – Update • Add aluminum hydroxide gel 2 cc PO BID

  41. Daisy - Echo 5 Months later • Coughing getting worse • Chest rad show no pulmonary edema • LA getting larger Therapeutic Plan – Update • Add torbutrol 2.5 mg PO PRN to control cough

  42. Daisy - Echo 18 Months after initial presentation • Owner discontinue pimobendan due to GI upset 20 months after initial presentation • Daisy is still alive. • Furosemide 20 mg PO TID • Hydralazine 5 mg PO BID • Spironolactone 12.5 mg PO BID • We don’t want to know how high her BUN is

  43. Chronic MV Disease • May be accompanied by similar TV disease (80%) • TV disease without MV disease is possible but rare • LHF and/or RHF can result • Right heart enlargement can develop due to pulmonary hypertension due to LHF • Myocardial failure and CHF are not directly related

  44. Chronic MV Disease Echo abnormalities: • LA and/or RA dilation, LV and/or RV dilation • Exaggerated IVS motion (toward RV in diastole) • Increased FS first, then later decreased FS • Thickened valve leaflets • If TV only affected, left heart can appear compressed, small and perhaps artifactually thick • Ruptured CT – • MV flips around in diastole • MV flies up into LA during systole • May see trailing CT, or CT floating in the LV

  45. Chronic MV Disease Video

  46. Jasper Signalment: • Middle Aged Adult Norwegian Forest Cat • Male Castrated • 13 pounds Chief Complaint: • Acute Dyspnea 1 day after sedation with ketamine and Rompun for grooming

  47. Jasper Immediate Diagnostic Plan: • Lasix 25 mg IM – give 1 hour in cage • 1 lateral thoracic radiograph Differential Diagnosis – Pleural effusion • Transudate - Hypoalbuminemia • Modified Transudate – Neoplasia, CHF • Exudate – Blood, Pyothorax, FIP • Chylothorax

  48. Jasper Initial Therapeutic Plan: • Thoracocentesis • Tapped both right and left thorax • Removed 400 ml of pink opaque fluid that resembled pepto bismol • Fluid had no “chunks” in it Differential Diagnosis – updated • Pyothorax • Chylothorax

  49. Jasper Initial Diagnostic Plan: • Fluid analysis • Total solids 5.1 • SG 1.033 • Color- pink before spun, white after • Clarity – opaque • Nucelated cells 8500/ml • RBC 130,000/ml • HCT 0.7%

  50. Jasper Initial Diagnostic Plan: • Fluid analysis • Lymphocytes 5600/ml • Monocytes 600/ml • Granulocytes 2300/ml • No bacteria seen • Triglycerides 1596 mg/dl • Cholesterol 59 mg/dl Chylothorax

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