practical cardiology case studies wendy blount, dvm nacogdoches tx wendy blount, dvm nacogdoches tx
TRANSCRIPT
Practical CardiologyCase StudiesPractical CardiologyCase Studies
Wendy Blount DVMNacogdoches TXWendy Blount DVMNacogdoches TX
GingerGinger
Signalmentbull 12 year old SF cocker spaniel
Chief complaintbull Several episodes of collapse during the past
monthbull Description matches partial seizurebull Rear legs get weak on walksbull Lethargic and dull in general
GingerGinger
Exambull Dark maroon oral mucous membranesbull Rear foot pads cyanotic (heart sounds)bull Split S2bull Neurologic exam normal except dull mental
status
GingerGinger
Differential Diagnosis ndash Split S2bull Pulmonic and aortic valves donrsquot close at the same time
ndash Pulmonary hypertensionndash Normal variation in giant dogsndash Reverse PDA
Differential Diagnosis - cyanosisbull Respiratory hypoxiabull Cardiac hypoxia
GingerGinger
Initial Diagnostic Planbull CBC GHP electrolytesbull Arterial blood gases Pulse oximetrybull ECGbull Thoracic radiographs
Bloodworkbull Tech couldnrsquot get enough serum for serologybull CBC ndash PCV 73bull GHP and electrolytes - normal
GingerGinger
DDx Differential Cyanosisbull FATE ndash Femoral Artery ThromboEmbolism
ndash Lack of femoral pulsesndash Feet cool to the touch
bull Right to Left shunt ndash ductus is distal to the brachiocephalic trunkndash Reverse PDAndash AV fistula with pulmonary hypertensionndash Tetralogy of Fallot
GingerGinger
Arterial blood gasesbull pO2 ndash 52 mmHg
bull pCO2 ndash 36 mmHg
bull all else normal
Pulse oximetrybull Lip ndash O2 sat 89
bull Vulva - O2 sat 67
GingerGinger
GingerGinger
GingerGinger
Thoracic radiographsbull Normal great vesselsbull Normal heart size (VHS 95)bull aortic bulge on VDbull No evidence of severe respiratory disease
which might cause hypoxiabull No evidence of heart failure
GingerGinger
ECGbull S wave mildly deep in leads I II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
GingerGinger
ECGbull S wave mildly deep in leads II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
Signalmentbull 12 year old SF cocker spaniel
Chief complaintbull Several episodes of collapse during the past
monthbull Description matches partial seizurebull Rear legs get weak on walksbull Lethargic and dull in general
GingerGinger
Exambull Dark maroon oral mucous membranesbull Rear foot pads cyanotic (heart sounds)bull Split S2bull Neurologic exam normal except dull mental
status
GingerGinger
Differential Diagnosis ndash Split S2bull Pulmonic and aortic valves donrsquot close at the same time
ndash Pulmonary hypertensionndash Normal variation in giant dogsndash Reverse PDA
Differential Diagnosis - cyanosisbull Respiratory hypoxiabull Cardiac hypoxia
GingerGinger
Initial Diagnostic Planbull CBC GHP electrolytesbull Arterial blood gases Pulse oximetrybull ECGbull Thoracic radiographs
Bloodworkbull Tech couldnrsquot get enough serum for serologybull CBC ndash PCV 73bull GHP and electrolytes - normal
GingerGinger
DDx Differential Cyanosisbull FATE ndash Femoral Artery ThromboEmbolism
ndash Lack of femoral pulsesndash Feet cool to the touch
bull Right to Left shunt ndash ductus is distal to the brachiocephalic trunkndash Reverse PDAndash AV fistula with pulmonary hypertensionndash Tetralogy of Fallot
GingerGinger
Arterial blood gasesbull pO2 ndash 52 mmHg
bull pCO2 ndash 36 mmHg
bull all else normal
Pulse oximetrybull Lip ndash O2 sat 89
bull Vulva - O2 sat 67
GingerGinger
GingerGinger
GingerGinger
Thoracic radiographsbull Normal great vesselsbull Normal heart size (VHS 95)bull aortic bulge on VDbull No evidence of severe respiratory disease
which might cause hypoxiabull No evidence of heart failure
GingerGinger
ECGbull S wave mildly deep in leads I II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
GingerGinger
ECGbull S wave mildly deep in leads II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
Exambull Dark maroon oral mucous membranesbull Rear foot pads cyanotic (heart sounds)bull Split S2bull Neurologic exam normal except dull mental
status
GingerGinger
Differential Diagnosis ndash Split S2bull Pulmonic and aortic valves donrsquot close at the same time
ndash Pulmonary hypertensionndash Normal variation in giant dogsndash Reverse PDA
Differential Diagnosis - cyanosisbull Respiratory hypoxiabull Cardiac hypoxia
GingerGinger
Initial Diagnostic Planbull CBC GHP electrolytesbull Arterial blood gases Pulse oximetrybull ECGbull Thoracic radiographs
Bloodworkbull Tech couldnrsquot get enough serum for serologybull CBC ndash PCV 73bull GHP and electrolytes - normal
GingerGinger
DDx Differential Cyanosisbull FATE ndash Femoral Artery ThromboEmbolism
ndash Lack of femoral pulsesndash Feet cool to the touch
bull Right to Left shunt ndash ductus is distal to the brachiocephalic trunkndash Reverse PDAndash AV fistula with pulmonary hypertensionndash Tetralogy of Fallot
GingerGinger
Arterial blood gasesbull pO2 ndash 52 mmHg
bull pCO2 ndash 36 mmHg
bull all else normal
Pulse oximetrybull Lip ndash O2 sat 89
bull Vulva - O2 sat 67
GingerGinger
GingerGinger
GingerGinger
Thoracic radiographsbull Normal great vesselsbull Normal heart size (VHS 95)bull aortic bulge on VDbull No evidence of severe respiratory disease
which might cause hypoxiabull No evidence of heart failure
GingerGinger
ECGbull S wave mildly deep in leads I II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
GingerGinger
ECGbull S wave mildly deep in leads II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
Differential Diagnosis ndash Split S2bull Pulmonic and aortic valves donrsquot close at the same time
ndash Pulmonary hypertensionndash Normal variation in giant dogsndash Reverse PDA
Differential Diagnosis - cyanosisbull Respiratory hypoxiabull Cardiac hypoxia
GingerGinger
Initial Diagnostic Planbull CBC GHP electrolytesbull Arterial blood gases Pulse oximetrybull ECGbull Thoracic radiographs
Bloodworkbull Tech couldnrsquot get enough serum for serologybull CBC ndash PCV 73bull GHP and electrolytes - normal
GingerGinger
DDx Differential Cyanosisbull FATE ndash Femoral Artery ThromboEmbolism
ndash Lack of femoral pulsesndash Feet cool to the touch
bull Right to Left shunt ndash ductus is distal to the brachiocephalic trunkndash Reverse PDAndash AV fistula with pulmonary hypertensionndash Tetralogy of Fallot
GingerGinger
Arterial blood gasesbull pO2 ndash 52 mmHg
bull pCO2 ndash 36 mmHg
bull all else normal
Pulse oximetrybull Lip ndash O2 sat 89
bull Vulva - O2 sat 67
GingerGinger
GingerGinger
GingerGinger
Thoracic radiographsbull Normal great vesselsbull Normal heart size (VHS 95)bull aortic bulge on VDbull No evidence of severe respiratory disease
which might cause hypoxiabull No evidence of heart failure
GingerGinger
ECGbull S wave mildly deep in leads I II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
GingerGinger
ECGbull S wave mildly deep in leads II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
Initial Diagnostic Planbull CBC GHP electrolytesbull Arterial blood gases Pulse oximetrybull ECGbull Thoracic radiographs
Bloodworkbull Tech couldnrsquot get enough serum for serologybull CBC ndash PCV 73bull GHP and electrolytes - normal
GingerGinger
DDx Differential Cyanosisbull FATE ndash Femoral Artery ThromboEmbolism
ndash Lack of femoral pulsesndash Feet cool to the touch
bull Right to Left shunt ndash ductus is distal to the brachiocephalic trunkndash Reverse PDAndash AV fistula with pulmonary hypertensionndash Tetralogy of Fallot
GingerGinger
Arterial blood gasesbull pO2 ndash 52 mmHg
bull pCO2 ndash 36 mmHg
bull all else normal
Pulse oximetrybull Lip ndash O2 sat 89
bull Vulva - O2 sat 67
GingerGinger
GingerGinger
GingerGinger
Thoracic radiographsbull Normal great vesselsbull Normal heart size (VHS 95)bull aortic bulge on VDbull No evidence of severe respiratory disease
which might cause hypoxiabull No evidence of heart failure
GingerGinger
ECGbull S wave mildly deep in leads I II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
GingerGinger
ECGbull S wave mildly deep in leads II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
DDx Differential Cyanosisbull FATE ndash Femoral Artery ThromboEmbolism
ndash Lack of femoral pulsesndash Feet cool to the touch
bull Right to Left shunt ndash ductus is distal to the brachiocephalic trunkndash Reverse PDAndash AV fistula with pulmonary hypertensionndash Tetralogy of Fallot
GingerGinger
Arterial blood gasesbull pO2 ndash 52 mmHg
bull pCO2 ndash 36 mmHg
bull all else normal
Pulse oximetrybull Lip ndash O2 sat 89
bull Vulva - O2 sat 67
GingerGinger
GingerGinger
GingerGinger
Thoracic radiographsbull Normal great vesselsbull Normal heart size (VHS 95)bull aortic bulge on VDbull No evidence of severe respiratory disease
which might cause hypoxiabull No evidence of heart failure
GingerGinger
ECGbull S wave mildly deep in leads I II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
GingerGinger
ECGbull S wave mildly deep in leads II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
Arterial blood gasesbull pO2 ndash 52 mmHg
bull pCO2 ndash 36 mmHg
bull all else normal
Pulse oximetrybull Lip ndash O2 sat 89
bull Vulva - O2 sat 67
GingerGinger
GingerGinger
GingerGinger
Thoracic radiographsbull Normal great vesselsbull Normal heart size (VHS 95)bull aortic bulge on VDbull No evidence of severe respiratory disease
which might cause hypoxiabull No evidence of heart failure
GingerGinger
ECGbull S wave mildly deep in leads I II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
GingerGinger
ECGbull S wave mildly deep in leads II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
GingerGinger
GingerGinger
Thoracic radiographsbull Normal great vesselsbull Normal heart size (VHS 95)bull aortic bulge on VDbull No evidence of severe respiratory disease
which might cause hypoxiabull No evidence of heart failure
GingerGinger
ECGbull S wave mildly deep in leads I II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
GingerGinger
ECGbull S wave mildly deep in leads II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
GingerGinger
Thoracic radiographsbull Normal great vesselsbull Normal heart size (VHS 95)bull aortic bulge on VDbull No evidence of severe respiratory disease
which might cause hypoxiabull No evidence of heart failure
GingerGinger
ECGbull S wave mildly deep in leads I II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
GingerGinger
ECGbull S wave mildly deep in leads II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
Thoracic radiographsbull Normal great vesselsbull Normal heart size (VHS 95)bull aortic bulge on VDbull No evidence of severe respiratory disease
which might cause hypoxiabull No evidence of heart failure
GingerGinger
ECGbull S wave mildly deep in leads I II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
GingerGinger
ECGbull S wave mildly deep in leads II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
ECGbull S wave mildly deep in leads I II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
GingerGinger
ECGbull S wave mildly deep in leads II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
GingerGinger
ECGbull S wave mildly deep in leads II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
ECGbull S wave mildly deep in leads II III aVFbull MEA 90o
bull Arrhythmia doesnrsquot seem likely
Differential Diagnosesbull Right to left shuntbull Pulmonary hypertension
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiology
bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogram
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertension
Echocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GingerGinger
Bubble Studybull Place venous catheterbull Shake 5-10 cc saline vigorouslybull Place US probe where you can look for shunting
ndash Long 4 chamber viewndash Abdominal aorta
bull Inject IV quicklybull Bubbles normally appear on the right (video)bull Watch for bubbles on the left (this means R to L shunt)bull False negatives when bubbles disperse quickly
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
Reverse PDAReverse PDA
bull Reverse PDAs are usually large providing no resistance to blood flowndash Ductus is often as large in diameter as the great vessels it
connects
bull increase in pulmonary artery pressure combined with the increase in pulmonary blood flow creates pathologic responses in the pulmonary arteries over time
bull a continuous murmur is heard during the first days to weeks of life but disappears before the eighth week
bull Often do well until polycythemia develops late in life
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
Reverse PDAReverse PDA
Treatmentbull Ligation of right to left shunting PDA results in death
due to pulmonary hypertensionndash Has been ligated in stages without causing deathndash Cyanosis and symptoms usually persist
bull Managed Medically by periodic phlebotomyndash Remove 10 mllb and replace with IV fluidsndash Eliminate hyperviscosity without inducing hypoxiandash Goal for PCV is 60-65ndash Excellent blood for RBC transfusion -)ndash Repeat when clinical signs return
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
Reverse PDAReverse PDA
Treatmentbull Hydroxyurea
ndash 30 mgkgday for 7 to 10 days followed by 15 mgkgday
ndash CBC q1-2 weeksndash DC when Bone marrow suppressionndash Resume lower dosendash Some dogs require higher dosesndash side effects ndash GI and sloughing of the nails
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
Reverse PDAReverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GabbyGabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GabbyGabby
Pre-Anesthetic ECG
bull Heart ratendash P rate is 160 bpm QRS rate is 100 bpm
bull Rhythmndash no consistent PR intervalndash P and QRS complexes are disassociated but each regular
25 mmsec
3rd Degree AV block
20mm = 1 mV
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GabbyGabby
bull Gabby was not spayed at 6 months of agebull When she reached 7 years of age she had her 4th litterbull She was referred to Drs Miller and Gordon at TAMU for
spayndash When induced her heart rate immediately fell to 40 and was
progressively droppingndash A temporary pacemaker was placedndash Gabby was spayed and recovered uneventfullyndash Gabby turned 17 years old in 2010 and has since passed on
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
GabbyGabby
Dear Doc
Because you took away my favorite pastime I have turned to a life of substance abuse
Itrsquos your fault
Love Gabby
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
3rd degree AV block3rd degree AV block
3rd Degree AV block is the most common cause of bradycardia in the cat
Treatment- catsbull Often no treatment needed for cats
ndash AV node pacemaker is 100 per minutendash AV node pacemaker is 40-60 per minute in the dog
bull Cats do well unless they undergo anesthesiabull Avoid drugs that increase vagal tone
ndash Alpha blockers ndash Dexdomitor Rompun
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
3rd degree AV block in Dogs3rd degree AV block in Dogs
bull Usually presents for syncope (HR 20-40 per minute)bull ldquoCannon waverdquo jugular pulses (bradycardia)bull Treated with pacemaker implantationbull Drug therapy not usually successful
ndash Usually no response to atropinendash Atropine often makes 2nd degree block go awayndash Some have tried theophylline
bull Prognosis poor without pacemakerbull If lactate is high emergency pacemaker is needed
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
3rd degree AV block in Dogs3rd degree AV block in Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
3rd degree AV block in Dogs3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
TripTrip
Signalmentbull 2 year old castrated male border collieChief ComplaintHistorybull Productive Cough weight loss for 2 monthsbull Breathing hard for a 2 daysbull Energy good did well in agility 4 days agobull Owner thinks has had lifelong PU-PDbull Has wanted to be in AC this summer ndash unlike
last summer when he enjoyed being outside
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
TripTrip
Exambull T 1022 P 168 R 42 CRT 3 secbull BCS 25bull BP 100bull Bounding pulses notable in dorsal pedal arterybull Precordial ndash exaggerated left apical heavebull Lung sounds clear
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
TripTrip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole
2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF
3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
TripTrip
Differential Diagnosesbull Aortic endocarditisbull SAS with aortic regurgitationbull Mitral regurgitation (endocarditis)
Diagnostic Planbull Thoracic radiographsbull EKGbull Echocardiography
TripTrip
EKGbull Normal sinus rhythm for 10 minutes
TripTrip
EKGbull Normal sinus rhythm for 10 minutes
TripTrip
EKGbull Normal sinus rhythm for 10 minutes
Thoracic Radiographsbull Interstitial pattern caudal lung fieldsbull Vertebral heart score 105bull Enlarged cranial pulmonary lobar veinbull Mildly enlarged left atriumbull Early left congestive heart failure
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PM
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PM
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PMbull LVIDD ndash 573 (n 313-34)bull IVSTS ndash 155 mm (n 126-137)bull LVIDS ndash 411 mm (188-207)bull FS = (573-411)573 = 28 (n 30-46)bull EF = 54 (n gt70)
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamberbull LA appeared mildly enlargedbull IVS bowed anteriorly toward RVbull No evidence of mitral encodarditis or
endocardiosisbull Vegetation on aortic valve
Trip - EchoTrip - Echo
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
TripTrip
EKGbull Normal sinus rhythm for 10 minutes
TripTrip
EKGbull Normal sinus rhythm for 10 minutes
TripTrip
EKGbull Normal sinus rhythm for 10 minutes
Thoracic Radiographsbull Interstitial pattern caudal lung fieldsbull Vertebral heart score 105bull Enlarged cranial pulmonary lobar veinbull Mildly enlarged left atriumbull Early left congestive heart failure
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PM
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PM
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PMbull LVIDD ndash 573 (n 313-34)bull IVSTS ndash 155 mm (n 126-137)bull LVIDS ndash 411 mm (188-207)bull FS = (573-411)573 = 28 (n 30-46)bull EF = 54 (n gt70)
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamberbull LA appeared mildly enlargedbull IVS bowed anteriorly toward RVbull No evidence of mitral encodarditis or
endocardiosisbull Vegetation on aortic valve
Trip - EchoTrip - Echo
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
TripTrip
EKGbull Normal sinus rhythm for 10 minutes
TripTrip
EKGbull Normal sinus rhythm for 10 minutes
Thoracic Radiographsbull Interstitial pattern caudal lung fieldsbull Vertebral heart score 105bull Enlarged cranial pulmonary lobar veinbull Mildly enlarged left atriumbull Early left congestive heart failure
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PM
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PM
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PMbull LVIDD ndash 573 (n 313-34)bull IVSTS ndash 155 mm (n 126-137)bull LVIDS ndash 411 mm (188-207)bull FS = (573-411)573 = 28 (n 30-46)bull EF = 54 (n gt70)
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamberbull LA appeared mildly enlargedbull IVS bowed anteriorly toward RVbull No evidence of mitral encodarditis or
endocardiosisbull Vegetation on aortic valve
Trip - EchoTrip - Echo
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
TripTrip
EKGbull Normal sinus rhythm for 10 minutes
Thoracic Radiographsbull Interstitial pattern caudal lung fieldsbull Vertebral heart score 105bull Enlarged cranial pulmonary lobar veinbull Mildly enlarged left atriumbull Early left congestive heart failure
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PM
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PM
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PMbull LVIDD ndash 573 (n 313-34)bull IVSTS ndash 155 mm (n 126-137)bull LVIDS ndash 411 mm (188-207)bull FS = (573-411)573 = 28 (n 30-46)bull EF = 54 (n gt70)
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamberbull LA appeared mildly enlargedbull IVS bowed anteriorly toward RVbull No evidence of mitral encodarditis or
endocardiosisbull Vegetation on aortic valve
Trip - EchoTrip - Echo
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PM
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PM
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PMbull LVIDD ndash 573 (n 313-34)bull IVSTS ndash 155 mm (n 126-137)bull LVIDS ndash 411 mm (188-207)bull FS = (573-411)573 = 28 (n 30-46)bull EF = 54 (n gt70)
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamberbull LA appeared mildly enlargedbull IVS bowed anteriorly toward RVbull No evidence of mitral encodarditis or
endocardiosisbull Vegetation on aortic valve
Trip - EchoTrip - Echo
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PM
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PMbull LVIDD ndash 573 (n 313-34)bull IVSTS ndash 155 mm (n 126-137)bull LVIDS ndash 411 mm (188-207)bull FS = (573-411)573 = 28 (n 30-46)bull EF = 54 (n gt70)
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamberbull LA appeared mildly enlargedbull IVS bowed anteriorly toward RVbull No evidence of mitral encodarditis or
endocardiosisbull Vegetation on aortic valve
Trip - EchoTrip - Echo
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Trip - EchoTrip - Echo
Short Axis ndash LV Apexbull No abnormalities noted
Short Axis ndash LV PMbull LVIDD ndash 573 (n 313-34)bull IVSTS ndash 155 mm (n 126-137)bull LVIDS ndash 411 mm (188-207)bull FS = (573-411)573 = 28 (n 30-46)bull EF = 54 (n gt70)
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamberbull LA appeared mildly enlargedbull IVS bowed anteriorly toward RVbull No evidence of mitral encodarditis or
endocardiosisbull Vegetation on aortic valve
Trip - EchoTrip - Echo
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamberbull LA appeared mildly enlargedbull IVS bowed anteriorly toward RVbull No evidence of mitral encodarditis or
endocardiosisbull Vegetation on aortic valve
Trip - EchoTrip - Echo
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamberbull LA appeared mildly enlargedbull IVS bowed anteriorly toward RVbull No evidence of mitral encodarditis or
endocardiosisbull Vegetation on aortic valve
Trip - EchoTrip - Echo
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Trip - EchoTrip - Echo
Short Axis ndash MVbull EPSS ndash 8 mm (n 0-6)
Short Axis ndash AoRVOTbull AoS ndash 202 (normal)bull LAD ndash 278 (n 190-205)bull LAAo ndash 278202 = 138 (n 08-13)bull Aortic valve leaflets are hyperechoic
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamberbull LA appeared mildly enlargedbull IVS bowed anteriorly toward RVbull No evidence of mitral encodarditis or
endocardiosisbull Vegetation on aortic valve
Trip - EchoTrip - Echo
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamberbull LA appeared mildly enlargedbull IVS bowed anteriorly toward RVbull No evidence of mitral encodarditis or
endocardiosisbull Vegetation on aortic valve
Trip - EchoTrip - Echo
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamberbull LA appeared mildly enlargedbull IVS bowed anteriorly toward RVbull No evidence of mitral encodarditis or
endocardiosisbull Vegetation on aortic valve
Trip - EchoTrip - Echo
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Trip - EchoTrip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamberbull LA appeared mildly enlargedbull IVS bowed anteriorly toward RVbull No evidence of mitral encodarditis or
endocardiosisbull Vegetation on aortic valve
Trip - EchoTrip - Echo
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Trip - EchoTrip - Echo
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Trip - EchoTrip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
TripTrip
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Present for FUO weight loss or heart failurebull Aortic much more common than mitralbull Dogs much more common than catsbull Many bacteria including Bartonellabull Breed predisposition
ndash Rottweiler Boxer Golden retrieverndash Newfoundland German shepard
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Valvular EndocarditisValvular Endocarditis
Clinical Featuresbull Abnormal valve + bacteremia = endocarditisbull Bacteremia caused routinely by
ndash Dental cleaningndash Brushing your teeth (chewing)ndash Constipation any GI illnessndash defecationndash Urinary catheterizationndash infection
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Valvular EndocarditisValvular Endocarditis
ECG abnormalities bull Tall wide P wave (LA enlargement)bull Tall R wave (LV enlargement)bull Ventricular arrhythmias common
ndash Treat if multiform of gt30 per minutendash Class I or III antiarrhythmicndash Sotalol 2-3 mgkg PO BID
Thoracic radiographsbull Left heart failure
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Valvular EndocarditisValvular Endocarditis
Echocardiographic abnormalitiesbull Thickened hyperechoic valvesbull Vegetation may flop around
ndash MV in diastole AV in systolebull Variable LV dilation (more with time)bull FS normal to low normal until myocardial failurebull MV endocarditis can be difficult to distinguish
from MV endocardiosis ndash Endocarditis dogs are systemically ill
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Valvular EndocarditisValvular Endocarditis
Treatmentbull Based on urine and blood culture and sensitivity
Bartonella PCRbull Antibiotics
ndash IV 3-5 days ndash broad spectrum until culture resultsndash SCIM 3-5 daysndash Then PO long term ndash often for life
bull Treat Heart failure (severe)bull Treat ventricular arrhythmia if presentbull Watch for and treat bacterial embolization of abdominal
organs skin IVDiscs CNS joints etcbull Watch for and treat immune complex disease
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Valvular EndocarditisValvular Endocarditis
Prognosisbull lt20 survivalbull Antibiotic therapy often required for lifebull Median survival is 6 days from diagnosis for aortic
endocarditisbull Survival is longer for mitral endocarditis
ndash LHF due to MR not as severe as AoR
(Client Handout)
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
MaximusMaximus
18 month old male Boxer
Chief Complaintbull Drastic and rapid weight lossbull Not eating wellbull Coughing up blood tinged fluid since yesterday
Exam Chest rads ECGbull Similar to Trip except temp 1038bull And BCS 2
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
MaximusMaximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)
bull Urine culture ndash Enterobacter susceptible to all
bull CBCndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
MaximusMaximus
Diagnosticsbull General Health Profile electrolytes
ndash BUN ndash 55 (n 10-29)ndash ALT ndash 225 (n 10-120)ndash Albumin ndash 22 (n 23-37)
bull Urinalysisndash USG ndash 1045ndash WBC 7-10hpf rare bacteria seen
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
MaximusMaximus
Treatment (58 lbs BCS 2 RR 66)bull Antibiotics
ndash IV - ampicillin 750 mg TID Baytril 150 mg BID x 3 daysndash IM ndash ampicillin 750 mg BID Baytril 150 mg x 3 daysndash PO ndash ampicillin 750 mg BID Baytril 136 mg PO for life
bull Furosemidendash 100 mg IV TID the first day - RR down to 28ndash Then 75 mg PO BID
bull Enalapril ndash 15 mg PO BID
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
MaximusMaximus
Treatment ndash Day 3 ndash RR 30 eating wellbull Chest x-rays
ndash Pulmonary edema much improved but mild amount still present
bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Added Spironolactone ndash 25 mg PO BID
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
MaximusMaximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normal
Treatment ndash Day 5bull Furosemide - 75 mg PO BIDbull Enalapril ndash 15 mg PO BID bull Spironolactone ndash increased to 50 mg PO BIDbull Added Hydralazine ndash 125 mg PO BID
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
MaximusMaximus
Diagnostics ndash Day 10 RR 30 BP 135 Wt 618 Temp 103bull Chest x-rays ndash perihilar edema resolvedbull BUN ndash 11 albumin 23bull Electrolytes ndash normalbull CBC ndash neutrophilia 23000ul
Continued this treatment for the rest of Maxrsquos life ndash 3 months
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
IkeIke
Signalmentbull 7 year old castrated male Persian cat
Chief Complaintbull Recurring anemiabull Episodes of weakness anorexia dullness and
salivationbull Constipation often associated with episodesbull Tremendous hair loss and 2 lb weight loss over 6
months
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
IkeIke
Exam ndash T 1003 P 180 R 40 BP 135bull Fleas++++bull Gallop rhythm followed by normal heart
sounds followed by 26 systolic murmurbull Hepatomegaly and mild to moderate ascitesbull Jugular vein distensionbull Did not do hepatojugular reflux testbull Tongue protrudes and tip is drybull Breathes with mouth open when stressed
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
IkeIke
Diagnosticsbull CBC ndash normalbull FeLVFIV ndash negativebull GHPelectrolytes ndash
ndash ALT ndash 218 (n 10-100)ndash Bili ndash 03 (high normal)ndash Albumin 17 (n 23-34)ndash K ndash 25 (n 29-42)
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
IkeIke
Diagnosticsbull Chest x-rays
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
IkeIke
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
IkeIke
Diagnosticsbull Diagnosis - Right heart failure with cardiomegalybull DDx ndash cardiomegaly
ndash Diaphragmatic herniandash pericardial effusionndash heart enlargement
bull HCM DCM RCMbull VSDbull Valvular disease
ndash Hypoalbuminemialiver disease may be contributing to ascites
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
IkeIke
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
IkeIke
Initial Treatmentbull No echo done because Ike became dyspneic
after chest radsbull Furosemide 5 mg PO BID (wt 5 lbs 7 oz)bull Potassium gluconate 2 mEq PO SIDbull Metronidazole 625 mg PO SID x 2 weeks
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
IkeIke
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
IkeIke
Recheck ndash 1 week - Exambull Ike tremendously improvedbull Weight gain of 5 ouncesbull Ascites has resolvedbull Hepatomegaly no longer presentbull P 160 RR 28 BP 110bull Haircoat seems improvedbull 26 systolic murmur loudest at the sternumbull No open mouth breathing or inc RR when stressed
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
IkeIke
Recheck ndash 1 week - Diagnosticsbull Electrolytes ndash K 27bull Albumin - 24 (normal)bull ALT - 134 (n 10-100)bull Bili - 03bull UPC ndash 05bull Bile Acids (fasting) - 157
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Short Axis ndash LV Apexbull Mild pericardial effusion
Short Axis ndash LV PMbull Mild pericardial effusionbull LV subjectively thickbull Papillary muscles really bigbull No evidence of pericardial hernia
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Short Axis ndash LV PMbull IVSTD ndash 102 (n 3-6)bull LVIDD ndash 141 (n 10-21)bull LVPWD ndash 695 (n 3-6)bull IVSTS ndash 1485 (4-9)bull LVIDS ndash 35 (n 4-10)bull LVPWS ndash 96 (n 4-11)bull FS ndash (141-35)141 = 745 EF = 98
Dx ndash HypertrophicCardiomyopathy
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOTbull RVOT looks subjectively enlargedbull LA and LA normalbull LAAo = 11188 = 126 (normal)
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Abdominal USbull No fluid present in the abdomenbull Main bile duct tortuousbull Pancreas normalbull Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Assessmentbull Hypertrophic Cardiomyopathy
ndash Biventricular failurendash Secondary pericardial effusion ascites hepatomegaly
bull Enlarged Pulmonary artery of unknown cause (DDx)ndash Heartworm diseasendash Pulmonary hypertension
bull Liver Dysfunction of unknown causendash Probable history of pancreatitisndash Possibly contributed to by passive congestion of RHF
bull Financial Resources for Ikersquos Diagnosis and Treatment have been depleted
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Ike - EchoIke - Echo
Treatment - Updatebull Finish metronidazole then start milk thistlebull Increase Kgluconate to 2 mEq PO BIDbull Continue furosemide 5 mg PO BIDbull Add enalapril 125 mg PO SID
ndash Recheck BUNlytes 5 daysndash If OK increase to BIDndash Recheck BUNlytes 5 days
bull Laxatone PRN for constipationbull Recheck echo chest rads in 6 months or sooner if RR
gt 40 at restbull Ike died acutely just prior to his 6 month recheck
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Pericardial EffusionPericardial Effusion
Clinical Featuresbull DDx
ndash Pericarditisndash Chronic CHF (usually RHF)ndash Blood ndash left atrial tear HSA coagulopathyndash Pericardial cystndash Idiopathicndash 50 are neoplasia ndash carefully look at RA
bull ECG ndash electrical alternans
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful not to confuse pericardial fat with
pericardial effusionndash Look at relative echogenicity
bull Careful not to confuse normal anechoic structures with pericardial effusionndash Descending aortandash Enlarged left auricle
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Careful to distinguish pericardial from pleural
effusionndash Pericardium not visualized with pleural effusionndash Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)ndash Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic herniabull Heart may swing back amp forth in the
pericardium
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Pericardial EffusionPericardial Effusion
Echocardiographic Abnormalitiesbull Cardiac tamponade
ndash Compression of RVndash Diastolic collapse of RVndash IVS may be flattened with paradoxical motionndash Pericardiocentesis is imperativendash Aggressive diuresis will reduce preload
bull Evaluation of heart base tumor prior to pericardiocentesis will be more thorough
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Pericardial EffusionPericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
TazTaz
Signalmentbull 7 year old neutered male sharpeibull Annual vaccines 2 weeks ago
Chief Complaintbull Hasnrsquot felt good since vaccinesbull Breathing really hardbull Belly is swellingbull Not eating
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
TazTaz
Exam ndash RR 77 mm pale CRT 4 secbull Positive hepatojugular refluxbull Ascitesbull Peripheral edema ndash ventral legs and ventral abdomenbull Muffled heart sounds
CBC panel lytes heartworm test bull No abnormalities noted
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
TazTaz
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
TazTaz
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
TazTaz
Echocardiogrambull Pronounced pericardial effusion with cardiac
tamponadebull Pericardiocentesis ndash 1 L fluid that resembles blood
ndash Does not clot after 20 minutesndash PCV 38 cytology non-septic exudate (hypersegmented
neutrophils)
bull IV fluid bolus 500 mlbull Echo measurements after tap normal
PT PTT ACTbull normal
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
TazTaz
Abdominal USbull Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogrambull Taz was VERY painful on the ride to Bryanbull Small amount of pericardial effusion ndash not enough to tapbull No cardiac masses detectedbull Abdominal ultrasound NSAFbull Discharged with no medications to recheck in one week
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
TazTaz
Recheck 1 weekbull Taz doing exceptionally wellbull No growth on culture and sensitivitybull Signs of right heart failure have resolved
bull No ascites dyspnea peripheral edema jugular distensionbull Abdominal palpation normal
bull Chest x-rays show VHS 11bull Echo shows 2 cm pericardial effusionbull Tapped again and dispensed pain medsbull Rx doxycycline 10 mgkg PO BID x 3 weeksbull Rx prednisone 05 mgkg PO SID x 2 weeks then QOD
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
TazTaz
Recheck 30 daysbull Exam chest rads and echo are normalbull Taper off prednisone over the next 30 daysbull Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Cardiac MassesCardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Cardiac MassesCardiac Masses
Echocardiographic Featuresbull Usually at the heart base or in the RAbull Careful not to confuse with
ndash Epicardial fat (especially on the AV groove when there is pericardial effusion)
ndash Trabeculae on the right auricle when floating in pericardial effusion
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
HankHank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
HankHank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
HankHank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
HankHank
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
HankHank
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
HankHank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
HankHank
EKGbull Tall P waves (05-06 mV)bull RA enlargementbull Deep S waves in leads I II and III (-13 to -15 mV)bull RV enlargementbull Tachycardia 200-210 bpmbull Under Buprenex-ace sedation
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Hank - EchoHank - Echo
Short Axis ndash LV Apexbull RV seems thickened
Short Axis ndash LV PM MV AoRVOTbull RV as thick as LV ndash markedly thickenedbull IVS is flattened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Hank - EchoHank - Echo
Short Axis ndash PAbull MPA dilatedbull RV as thick as LV ndash markedly thickened
Long Axis ndash 4 Chamberbull Aberrant septum dividing RA into 2 chambers ndash cranial
and caudal
Long Axis ndash LVOTbull RV as thick as LV ndash markedly thickened
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Hank - EchoHank - Echo
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Hank - EchoHank - Echo
Diagnosisbull Likely Pulmonic Stenosisbull DDx RV thickening
ndash Heartworms impossible in a 10 week old puppyndash Pulmonary hypertension rare in a 10 week old puppy
bull Need Doppler to confirm and to determine gradientbull Cor triatriatum dexter
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Hank - EchoHank - Echo
Plan ndash updatedbull Referral to TAMU for balloon valvuloplastybull Atenolol 05 mgkg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalier
bull Often valvular and subvalvularbull Valvular defect can be corrected by valvuloplastybull Prognosis varies depending on severity
ndash Mild ndash less than 50 mm Hg gradientndash Moderate ndash 50-100 mm Hgndash Severe - gt100 mm Hg
bull Can be progressive
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Pulmonic StenosisPulmonic Stenosis
Clinical featuresbull Bulldogs and Boxers can have left coronary artery
anomaly which can preclude balloon valvuloplastybull Arrhythmia is much more common than RHFbull May be part of Tetralogy of Fallot
ndash PSndash RV hypertrophyndash VSDndash Overriding aorta
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Pulmonic StenosisPulmonic Stenosis
Coronary Artery Anomalybull Instead of R and L coronary
aa there is a single coronary a
bull It splits and the left branch encircles the pulmonary a
bull It can be ruptured if the PS is ballooned
bull These dogs may have normal PV and functional PS due to this anomaly
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-
Pulmonic StenosisPulmonic Stenosis
Echocardiographic abnormalitiesbull RV thickeningbull Post-stenotic dilatation of MPAbull Pulmonic valve may be thickened with poor movementbull Paradoxical septal motion may be noted in severe casesbull Tricuspid dysplasia is a common concurrent malformation
ndash RHF is rare in dogs with PS alonendash Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)
- Practical Cardiology Case Studies
- Ginger
- Ginger (2)
- Ginger (3)
- Ginger (4)
- Ginger (5)
- Ginger (6)
- Ginger (7)
- Ginger (8)
- Ginger (9)
- Ginger (10)
- Ginger (11)
- Ginger (12)
- Ginger (13)
- Ginger (14)
- Ginger (15)
- Ginger (16)
- Ginger (17)
- Reverse PDA
- Reverse PDA (2)
- Reverse PDA (3)
- Reverse PDA (4)
- Gabby
- Gabby (2)
- Gabby (3)
- Gabby (4)
- 3rd degree AV block
- 3rd degree AV block in Dogs
- 3rd degree AV block in Dogs (2)
- 3rd degree AV block in Dogs (3)
- Trip
- Trip (2)
- Trip (3)
- Trip (4)
- Trip (5)
- Trip (6)
- Trip (7)
- Trip - Echo
- Trip - Echo (2)
- Trip - Echo (3)
- Trip - Echo (4)
- Trip - Echo (5)
- Trip - Echo (6)
- Trip - Echo (7)
- Trip - Echo (8)
- Trip - Echo (9)
- Trip - Echo (10)
- Trip - Echo (11)
- Trip (8)
- Valvular Endocarditis
- Valvular Endocarditis (2)
- Valvular Endocarditis (3)
- Valvular Endocarditis (4)
- Valvular Endocarditis (5)
- Valvular Endocarditis (6)
- Valvular Endocarditis (7)
- Maximus
- Maximus (2)
- Maximus (3)
- Maximus (4)
- Maximus (5)
- Maximus (6)
- Maximus (7)
- Ike
- Ike (2)
- Ike (3)
- Ike (4)
- Ike (5)
- Ike (6)
- Ike (7)
- Ike (8)
- Ike (9)
- Ike (10)
- Ike (11)
- Ike (12)
- Ike - Echo
- Ike - Echo (2)
- Ike - Echo (3)
- Ike - Echo (4)
- Ike - Echo (5)
- Ike - Echo (6)
- Ike - Echo (7)
- Ike - Echo (8)
- Ike - Echo (9)
- Ike - Echo (10)
- Ike - Echo (11)
- Ike - Echo (12)
- Ike - Echo (13)
- Ike - Echo (14)
- Ike - Echo (15)
- Ike - Echo (16)
- Ike - Echo (17)
- Pericardial Effusion
- Pericardial Effusion (2)
- Pericardial Effusion (3)
- Pericardial Effusion (4)
- Pericardial Effusion (5)
- Taz
- Taz (2)
- Taz (3)
- Taz (4)
- Taz (5)
- Taz (6)
- Taz (7)
- Taz (8)
- Cardiac Masses
- Cardiac Masses (2)
- Hank
- Hank (2)
- Hank (3)
- Hank (4)
- Hank (5)
- Hank (6)
- Hank (7)
- Hank - Echo
- Hank - Echo (2)
- Hank - Echo (3)
- Hank - Echo (4)
- Hank - Echo (5)
- Hank - Echo (6)
- Hank - Echo (7)
- Pulmonic Stenosis
- Pulmonic Stenosis (2)
- Pulmonic Stenosis (3)
- Pulmonic Stenosis (4)
-