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 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

Jake Differential Diagnosis - Cough Respiratory Disease Cardiovascular Disease Both

Jake Diagnostic Plan (B Client) Blood Pressure Chest X-rays 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

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

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

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

Jake - Echo Transverse - LV Papillary Muscles FS = LVIDD – LVIDS LVIDD (72.1-67.1)/72.1 = 7% (n 30-46%) EF = 15% (n >70%) 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)

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

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

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

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)

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

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

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

Dilated Cardiomyopathy Video

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.

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

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

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

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

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

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

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

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

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

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

Daisy Diagnostic Plan - updated Recheck – 1 week 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

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

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

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

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

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

Daisy - Echo Short Axis – LV apex Short Axis – LV papillary muscles 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

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%)

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)

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

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

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

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

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

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

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

Chronic MV Disease Video

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

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

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

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%

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

Jasper DDx Chylothorax Trauma – was chewed by a dog 2-3 mos ago Right Heart Failure Pericardial Disease Heartworm Disease Neoplasia Lymphoma Thymoma Idiopathic

Jasper Diagnostic Plan - Updated PE & Cardiovascular exam CBC, general health profile, electrolytes Occult heartworm test Post-tap chest x-rays Echocardiogram

Jasper Exam Temp 100, P 180, R 48, BCS 3, BP 115 3/6 systolic murmur Anterior mediastinum compressible Pleural rubs No jugular pulses, no hepatojugular reflux Peripheral pulses slightly weak Mucous membranes pink, CRT 3 sec

Jasper Bloodwork Occult Heartworm Test - negative CBC – normal GHP – Glucose 134 (n 70-125) Cholesterol 193 & TG 137 (both normal) Chest X-rays Post-tap chest x-rays

Jasper Chest X-rays Minimal pleural effusion No cranial mediastinal masses Normal cardiac silhouette (VHS 7.5) Normal pulmonary vasculature Lungs remain scalloped

Jasper – Echo Short Axis – LV apex No abnormalities noted Short Axis – LV PM IVSTD – 8.8 mm (n 3-6) LVIDD – 16.2 mm (normal) LVPWD – 7.2 mm (n 3-6) IVSTS – 9.8 mm (n 4-9) LVIDS – 10.5 mm (normal) FS – 35%

Jasper – Echo Short Axis – MV No abnormalities noted Short Axis – Ao/RVOT Smoke in the LA AoS – 11.7 mm ( normal) LAD – 10.5 (normal) LA/Ao – 0.9 (normal)

Jasper – Echo Short Axis – PA Difficult to evaluate due to “rib shadows” Long Axis – 4 Chamber Hyperechoic “thingy” in the LA, with smoke Long Axis – LVOT Aortic valve seems hyperechoic, but not nodular 2-3 cm thrombus free in the LA

Jasper – Echo Short Axis – Ao/RVOT LA 2-3x normal size, with Smoke AoS – 11.7 mm ( normal) LAD – 29 mm (n 7-17) LA/Ao – 2.5 (n 0.8-1.3)

Jasper – Echo Therapeutic Plan - Updated Furosemide 12.5 mg PO BID Enalapril 2.5 mg PO BID Rutin 250 mg PO BID Low fat diet Plavix 18.75 mg PO SID Lovenox 1 mg/kg BID Fragmin 1 mg/kg BID Clot busters only send the clot sailing

Jasper – Echo Recheck – 1 week Jasper doing expectionally well –back to normal. Lateral chest radiograph Jasper declined all other diagnostics, without deep sedation/anesthesia Will do BUN, Electrolytes, BP, recheck echo to assess thrombus in one month

Jasper – Echo Recheck – 1 month Jasper doing expectionally well Lateral chest radiograph – no change Jasper declined all other diagnostics, without deep sedation/anesthesia Will do BUN, Electrolytes, BP, recheck echo to assess thrombus at 6 month check-up.

Hypertrophic Cardiomyopathy Clinical Characteristics Diastolic dysfunction – heart does not fill well Poor cardiac perfusion Most severe disease in young to middle aged males Atria sometimes look enlarged on rads Can present as Murmur on physical exam Heart failure (often advanced at first sign) Acute death Saddle thrombus

Hypertrophic Cardiomyopathy Echocardiographic Abnormalities LV and/or IVS thicker than 6 mm in diastole Symmetrical or asymmetrical Can be only a thick IVS Can be primarily very thick papillary muscles LVIDD usually normal to slightly reduced FS normal to increased, unless myocardial failure developing LVIDS sometimes 0 mm

Hypertrophic Cardiomyopathy Echocardiographic Abnormalities LA often enlarged RA sometimes also enlarged “Smoke” can be seen in the LA Rarely a thrombus in the LA Transesophageal US more sensitive at detecting LA thrombi Borderline thickened LV should not be diagnosed as HCM without LA enlargement

Hypertrophic Cardiomyopathy DDx LV thickening Hypertension Hyperthyroidism (Chronic renal failure)

Hypertrophic Cardiomyopathy Treatment HCM Manage heart failure Therapeutic thoracocentesis in a crisis Diuretics ACE inhibitors Beta blockers – if persistent tachycardia Calcium channel blockers – if thickening significant Treat hypertension if present

Hypertrophic Cardiomyopathy Video