1. Basic Echocardiography Case Studies
Wendy Blount, DVM
Nacogdoches TX

2. 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

3. 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

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

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

6. Trip - Echo Short Axis – LV Apex No abnormalities noted
Short Axis – LV PM
LVIDD – 57.3 (n )
IVSTS – 15.5 mm (n )
LVIDS – 41.1 mm ( )
FS = ( )/57.3 = 28% (n 30-46%)
EF = 54% (n >70%)

7. Trip - Echo Short Axis – MV EPSS – 8 mm (n 0-6) Short Axis – Ao/RVOT
AoS – 20.2 (normal)
LAD – 27.8 (n )
LA/Ao – 27.8/20.2 = 1.38 (n )
Aortic valve leaflets are hyperechoic

8. 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

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

10. 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

11. 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

12. 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.

13. Valvular Endocarditis
Video

14. 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%

15. Maximus Diagnostics General Health Profile, electrolytes Urinalysis
BUN – 55 (n 10-29)
ALT – 225 (n )
Albumin – 2.2 (n )
Urinalysis
USG – 1.045
WBC 7-10/hpf, rare bacteria seen

16. 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 mV x 0.05 msec
(LV enlargement)

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. Ike Diagnostics CBC – normal FeLV/FIV – negative GHP/electrolytes –
ALT – 218 (n )
Bili – 0.3 (high normal)
Albumin 1.7 (n )
K – 2.5 (n )

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

25. 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

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

27. 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

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

29. 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

30. Ike Recheck – 1 week - Diagnostics Electrolytes – K 2.7
Albumin (normal)
ALT (n )
Bili - 0.3
UPC – 0.5
Bile Acids (fasting) - 157

31. Ike - Echo Short Axis – LV Apex Mild pericardial effusion
Short Axis – LV PM
LV subjectively thick
No evidence of pericardial hernia

32. 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 – (4-9)
LVIDS – 3.5 (n 4-10)
LVPWS – 9.6 (n 4-11)
FS – ( )/14.1 = 74.5% EF = 98%

33. 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)

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

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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

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

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

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

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

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

47. 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

48. 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 bpm
Under buprenex-ace sedation

49. 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

50. 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

51. 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)

52. 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

53. 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)

54. 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 – mm Hg
Severe - >100 mm Hg
Can be progressive

55. 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

56. 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