1. Basic Echocardiography Case 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 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

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

7. Jake Diagnostic Plan – 2nd Wave (2 pm) EKG Echocardiogram
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 FS = LVIDD – LVIDS LVIDD
( )/72.1 = 7%
(n 30-46%)
EF = 15% (n >70%)
Transverse - LV Papillary Muscles
IVSTD – 9.7 mm (n )
LVIDD – 72.1 mm (n 43-48)
LVPWD – 15.1 mm (n )
IVSTS – 11.9 mm (n )
LVIDS – 67.1 mm (n )
LVPWS – 13.0 mm (n )

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 )
LA:Ao = 44.7/23.1 = 1.9 (n )
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 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 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

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 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 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 Short Axis – LV papillary muscles
LV looks big
Short Axis – LV papillary muscles
IVSTD – 6.0 mm – low normal
LVIDD – 35 mm (n )
LVPWD – 4.3 mm – low normal
IVSTS – 9.4 mm – normal
LVIDS – 25 mm (n )
LVPWS – 8.4 mm - normal

36. Daisy - Echo Short Axis – LV papillary muscles
IVSTD – 6.0 mm – low normal
LVIDD – 35 mm (n )
LVPWD – 4.3 mm – low normal
IVSTS – 9.4 mm – normal
LVIDS – 25 mm (n )
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 )
LA/Ao = 2.5 (n )

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 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 Chylothorax
Lymphocytes 5600/ml
Monocytes 600/ml
Granulocytes 2300/ml
No bacteria seen
Triglycerides 1596 mg/dl
Cholesterol 59 mg/dl
Chylothorax

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

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

53. 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

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

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

56. 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%

57. 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)

58. 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

59. 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 )

60. 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 mg PO SID
Lovenox 1 mg/kg BID
Fragmin 1 mg/kg BID
Clot busters only send the clot sailing

61. 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

62. 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.

63. 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

64. 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

65. 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

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

67. 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

68. Hypertrophic Cardiomyopathy
Video