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 Owner thinks has had lifelong PU-PD Has wanted to be in AC this summer – unlike last summer when he enjoyed being outside

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

Trip Differential Diagnoses Aortic endocarditis SAS with aortic regurgitation Mitral regurgitation (endocarditis?) Diagnostic Plan Thoracic radiographs EKG Echocardiography

Trip EKG Normal sinus rhythm for 10 minutes Thoracic Radiographs Interstitial pattern caudal lung fields Vertebral heart score 10.5

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 - 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 - 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 - Echo Long Axis – LVOT Hyperechoic thickened mitral valve leaflets Diagnosis Aortic endocarditis Therapeutic Plan Elected euthanasia due to poor prognosis

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 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 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 Endocarditis Video

Maximus Urine culture Diagnostics Blood culture CBC negative (2 samples 2 hours apart) Urine culture Enterobacter susceptible to all CBC neutrophilia 23,100/ul Mild anemia – PCV 35.5%

Maximus Diagnostics General Health Profile, electrolytes Urinalysis 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

Maximus Diagnostics Thoracic Radiographs EKG 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)

Maximus Treatment (58 lbs, BCS 2, RR 66) Antibiotics Furosemide 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

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

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

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

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

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

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)

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

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

Ike DDx Hypoalbuminemia Liver disease PLN PLE unlikely with no clinical signs Sequestration in ascites

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

Ike Recheck Scheduled for 1 week Echocardiogram Electrolytes Abdominal US UPC bile acids Fluid analysis if ascites fails to resolve

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

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 Short Axis – LV Apex Mild pericardial effusion Short Axis – LV PM LV subjectively thick No evidence of pericardial hernia

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 - 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 - Echo Short Axis – PA Enlarged main pulmonary artery RV enlarged Long Axis – 4 Chamber No apparent enlargement of LA LV thickened

Ike - Echo Long Axis – LVOT No apparent enlargement of LA LV thickened

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 - 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 Laxatone PRN for constipation Recheck echo, chest rads in 6 months or sooner if RR > 40 at rest

Pericardial Effusion Clinical Features DDx ECG – electrical alternans Pericarditis Chronic CHF Blood – left atrial tear, HSA, coagulopathy Pericardial cyst Idiopathic 50% are neoplasia – carefully look at RA ECG – electrical alternans

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 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 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 Effusion Video Pericardial Effusion Video Pleural Effusion Video Consolidated Lung Lobe Video Normal thorax Video Mediastinal Mass

Hank Signalment 10 week old male schnauzer Chief Complaint Loud heart murmur heard on examination for routine vaccinations Suspect congenital heart defect

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

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

Hank Initial Differential Diagnoses Pulmonic stenosis Aortic Stenosis Initial Diagnostic Plan Chest x-rays EKG Echocardiogram

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

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 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 - 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

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 - 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 - 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 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 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 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