basic echocardiography case studies

Basic EchocardiographyCase Studies

Basic EchocardiographyCase Studies

Wendy Blount, DVMNacogdoches TXWendy Blount, DVMNacogdoches TX

TripTrip

Signalment• 2 year old castrated male border collieChief Complaint/History• Productive Cough, weight loss for 2 months• Breathing hard for a 2 days• Energy good; did well in agility 4 days ago• Owner thinks has had lifelong PU-PD• Has wanted to be in AC this summer – unlike

last summer when he enjoyed being outside

TripTrip

Exam• T 102.2, P 168, R 42, CRT 3 sec, BCS 2.5, BP 100• 3 murmurs:

– To-and-fro murmur, 3/6, PMI left base– Holosystolic murmur 3/6 over rest of chest– 2/6 ejection murmur PMI Carotid

• Bounding pulses, notable in small arteries• Precordial – exaggerated left apical heave• Lung sounds clear

TripTrip

Differential Diagnoses• Aortic endocarditis• SAS with aortic regurgitation• Mitral regurgitation (endocarditis?)

Diagnostic Plan• Thoracic radiographs• EKG• Echocardiography

TripTrip

EKG• Normal sinus rhythm for 10 minutes

Thoracic Radiographs• Interstitial pattern caudal lung fields• Vertebral heart score 10.5

Trip - EchoTrip - Echo

Short Axis – LV Apex• No abnormalities noted

Short Axis – LV PM• LVIDD – 57.3 (n 31.3-34)• IVSTS – 15.5 mm (n 12.6-13.7)• LVIDS – 41.1 mm (18.8-20.7)• FS = (57.3-41.1)/57.3 = 28% (n 30-46%)• EF = 54% (n >70%)


Short Axis – MV• EPSS – 8 mm (n 0-6)

Short Axis – Ao/RVOT• AoS – 20.2 (normal)• LAD – 27.8 (n 19.0-20.5)• LA/Ao – 27.8/20.2 = 1.38 (n 0.8-1.3)• Aortic valve leaflets are hyperechoic


Short Axis – PA• No abnormalities noted

Long Axis – 4 Chamber• LA appeared mildly enlarged• IVS bowed anteriorly toward RV• No evidence of mitral encodarditis or

endocardiosis


Long Axis – LVOT• Hyperechoic thickened mitral valve leaflets

Diagnosis• Aortic endocarditis

Therapeutic Plan• Elected euthanasia due to poor prognosis

Valvular EndocarditisValvular Endocarditis

Clinical Features• Present for FUO, weight loss or heart failure• Aortic much more common than mitral• Dogs much more common than cats• Many bacteria including Bartonella• Poor prognosis long term• Breed predisposition

– Rottweiler, Boxer, Golden retriever– Newfoundland, German shepard


Echocardiographic abnormalities• Thickened, hyperechoic valves• Vegetation may flop around

– MV in diastole, AV in systole

• Variable LV dilation (more with time)• FS normal to low normal until myocardial failure• MV endocarditis can be difficult to distinguish

from MV endocardiosis – Endocarditis dogs are systemically ill


Treatment• Based on urine and blood culture and sensitivity• Antibiotics

– IV 3-5 days – broad spectrum until culture results– SC/IM 35 days– Then PO long term – often for life

• Treat Heart failure (severe)• Treat ventricular arrhythmia if present• Watch for and treat bacterial embolization of abdominal

organs, skin, IVDiscs, CNS, joints, etc.


Video

MaximusMaximus

Diagnostics• Blood culture

– negative (2 samples 2 hours apart)

• Urine culture – Enterobacter susceptible to all

• CBC– neutrophilia 23,100/ul– Mild anemia – PCV 35.5%

MaximusMaximus

Diagnostics• General Health Profile, electrolytes

– BUN – 55 (n 10-29)– ALT – 225 (n 10-120)– Albumin – 2.2 (n 2.3-3.7)

• Urinalysis– USG – 1.045– WBC 7-10/hpf, rare bacteria seen

MaximusMaximus

Diagnostics• Thoracic Radiographs

– Severe perihilar and interstitial edema– VHS 12.5– Pulmonary lobar veins 2X arteries

• EKG– Normal sinus rhythm– P wave 0.5 mV tall x 0.06 msec (tall and wide P wave)– QRS complex tall 25-30 mV x 0.05 msec– (LV enlargement)

MaximusMaximus

Treatment (58 lbs, BCS 2, RR 66)• Antibiotics

– IV - ampicillin 750 mg TID, Baytril 150 mg BID x 3 days– IM – ampicillin 750 mg BID, Baytril 150 mg x 3 days– PO – ampicillin 750 mg BID, Baytril 136 mg PO for life

• Furosemide– 100 mg IV TID the first day - RR down to 28– Then 75 mg PO BID

• Enalapril – 15 mg PO BID

MaximusMaximus

Treatment – Day 3 – RR 30• Chest x-rays

– Pulmonary edema much improved, but mild amount still present

• Furosemide - 75 mg PO BID• Enalapril – 15 mg PO BID • Added Spironolactone – 25 mg PO BID

MaximusMaximus

Diagnostics – Day 5 – RR 36, BP 150• Chest x-rays - No change• BUN – 43• Electrolytes - normal

Treatment – Day 5• Furosemide - 75 mg PO BID• Enalapril – 15 mg PO BID • Spironolactone – increased to 50 mg PO BID• Added Hydralazine – 12.5 mg PO BID

MaximusMaximus

Diagnostics – Day 10 RR 30, BP 135, Wt 61.8, Temp 103• Chest x-rays – perihilar edema resolved• BUN – 11, albumin 2.3• Electrolytes – normal• CBC – neutrophilia 23,000/ul

Continued this treatment for the rest of Max’s life – 3 months

IkeIke

Signalment• 7 year old castrated male Persian cat

Chief Complaint• Recurring anemia• Episodes of weakness, anorexia, dullness and

salivation• Constipation often associated with episodes• Tremendous hair loss and 2 lb weight loss over 6

months

IkeIke

Exam – T 100.3, P 180, R 40, BP 135• Fleas++++• Gallop rhythm, followed by normal heart

sounds, followed by 2/6 systolic murmur• Hepatomegaly and mild to moderate ascites• Jugular vein distension• Did not do hepatojugular reflux test• Tongue protrudes and tip is dry• Breathes with mouth open when stressed

IkeIke

Diagnostics• CBC – normal• FeLV/FIV – negative• GHP/electrolytes –

– ALT – 218 (n 10-100)– Bili – 0.3 (high normal)– Albumin 1.7 (n 2.3-3.4)– K – 2.5 (n 2.9-4.2)

IkeIke

Diagnostics• Chest x-rays

– Elevated trachea – Generalized cardiomegaly – VHS 9– Distended caudal vena cava– Hepatomegaly– Ascites

IkeIke

Diagnostics• Diagnosis - Right heart failure with cardiomegaly

• DDx – cardiomegaly– Diaphragmatic hernia– pericardial effusion– heart enlargement

• HCM, DCM, RCM• VSD• Valvular disease

– Hypoalbuminemia/liver disease may be contributing to ascites

IkeIke

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

IkeIke

Initial Treatment• No echo done because Ike became dyspneic

after chest rads• Furosemide 5 mg PO BID (wt 5 lbs 7 oz)• Potassium gluconate 2 mEq PO SID• Metronidazole 625 mg PO SID x 2 weeks

IkeIke

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

IkeIke

Recheck – 1 week - Exam• Ike tremendously improved• Weight gain of 5 ounces• Ascites has resolved• Hepatomegaly no longer present• P 160, RR 28, BP 110• Haircoat seems improved• 2/6 systolic murmur loudest at the sternum• No open mouth breathing or inc RR when stressed

IkeIke

Recheck – 1 week - Diagnostics• Electrolytes – K 2.7• Albumin - 2.4 (normal)• ALT - 134 (n 10-100)• Bili - 0.3• UPC – 0.5• Bile Acids (fasting) - 157

Ike - EchoIke - Echo

Short Axis – LV Apex• Mild pericardial effusion

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


Short Axis – LV PM• IVSTD – 10.2 (n 3-6)• LVIDD – 14.1 (n 10-21)• LVPWD – 6.95 (n 3-6)• IVSTS – 14.85 (4-9)• LVIDS – 3.5 (n 4-10)• LVPWS – 9.6 (n 4-11)• FS – (14.1-3.5)/14.1 = 74.5% EF = 98%


Short Axis – LV MV• EPSS – 2 mm

Short Axis – LA/RVOT• RVOT looks subjectively enlarged• LA and LA normal• LA/Ao = 11.1/8.8 = 1.26 (normal)


Short Axis – PA• Enlarged main pulmonary artery• RV enlarged

Long Axis – 4 Chamber• No apparent enlargement of LA• LV thickened


Long Axis – LVOT• No apparent enlargement of LA• LV thickened


Abdominal US• No fluid present in the abdomen• Main bile duct tortuous• Pancreas normal• Did not do liver aspirate because Ike would not

tolerate it without general anesthesia


Treatment - Update• Finish metronidazole, then start milk thistle• Increase Kgluconate to 2 mEq PO BID• Continue furosemide 5 mg PO BID• Add enalapril 1.25 mg PO SID

– Recheck BUN/lytes 5 days– If OK, inrease to BID– Recheck BUN/lytes 5 days

• Laxatone PRN for constipation• Recheck echo, chest rads in 6 months or sooner if RR

> 40 at rest

Pericardial EffusionPericardial Effusion

Clinical Features• DDx

– Pericarditis– Chronic CHF– Blood – left atrial tear, HSA, coagulopathy– Pericardial cyst– Idiopathic– 50% are neoplasia – carefully look at RA

• ECG – electrical alternans


Echocardiographic Abnormalities• Careful not to confuse pericardial fat with

pericardial effusion– Look at relative echogenicity

• Careful not to confuse normal anechoic structures with pericardial effusion– Descending aorta– Enlarged left auricle


Echocardiographic Abnormalities• Careful to distinguish pericardial from pleural

effusion– Pericardium not visualized with pleural effusion– Collapsed lung lobes may be seen with pleural

effusion (look like liver)– Careful not to confuse with liver in a

peritineopericardial diaphragmatic hernia

• Heart my swing back & forth in the pericardium


Echocardiographic Abnormalities• Cardiac tamponade

– Compression of RV– Diastolic collapse of RV– IVS may be flattened with paradoxical motion– Pericardiocentsis is imperative– Aggressive diuresis will reduce preload

• Evaluation of heart base tumor prior to pericardiocentesis will be more thorough


Video Pericardial Effusion

Video Pleural Effusion

Video Consolidated Lung Lobe

Video Normal thorax

Video Mediastinal Mass

HankHank

Signalment• 10 week old male schnauzer

Chief Complaint• Loud heart murmur heard on examination for routine

vaccinations• Suspect congenital heart defect

HankHank

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

HankHank

Initial Differential Diagnoses• Pulmonic stenosis• Aortic Stenosis

Initial Diagnostic Plan• Chest x-rays• EKG• Echocardiogram

HankHank

Thoracic radiographs• Dorsally elevated trachea• Vertebral heart score 9.5• Right heart enlargement• Right auricular/atrial enlargement• Distended caudal vena cava• Bulge at main pulmonary artery

HankHank

EKG• Tall P waves (0.5-0.6 mV)• RA enlargement• Deep S waves in leads I, II and III (-13 to -15 mV)• RV enlargement• Tachycardia 200-210 bpm• Under buprenex-ace sedation

Hank - EchoHank - Echo

Short Axis – LV Apex• RV seems thickened

Short Axis – LV PM, MV, Ao/RVOT• RV as thick as LV – markedly thickened• IVS is flattened


Short Axis – PA• MPA dilated• RV as thick as LV – markedly thickened

Long Axis – 4 Chamber• Aberrant septum dividing RA into 2 chambers – cranial

and caudal

Long Axis – LVOT• RV as thick as LV – markedly thickened


Diagnosis• Likely Pulmonic Stenosis• DDx RV thickening• Need Doppler to confirm, and to determine gradient• Cor triatriatum dexter

Plan – updated• Referral to TAMU for ballon valvuloplasty• Atenolol 0.5 mg/kg PO BID (monitor weight to increased

dose PRN until cath procedure)


Diagnosis• Likely Pulmonic Stenosis• DDx RV thickening

– Heartworms impossible in a 10 week old puppy– Pulmonary hypertension rare in a 10 week old puppy

• Need Doppler to confirm, and to determine gradient• Cor triatriatum dexter


Plan – updated• Referral to TAMU for ballon valvuloplasty• Atenolol 0.5 mg/kg PO BID (monitor weight to

increased dose PRN until cath procedure)

Pulmonic StenosisPulmonic Stenosis

Clinical features• Many breed predispositions

– Bulldog, chihuahua, Beagle, Cavalier

• Often valvular and subvalvular• Valvular defect can be corrected by valvuloplasty• Prognosis varies, depending on severity

– Mild – less than 50 mm Hg gradient– Moderate – 50-100 mm Hg– Severe - >100 mm Hg

• Can be progressive


Clinical features• Bulldogs can have left coronary artery anomaly, which

can preclude balloon valvuloplasty• Arrhythmia is much more common than RHF• May be part of Tetralogy of Fallot

– PS– RV hypertrophy– VSD– Overriding aorta


Echocardiographic abnormalities• RV thickening• Post-stenotic dilitation of MPA• Pulmonic valve may be thickened with poor movement• Paradoxical septal motion may be noted in severe

cases

basic echocardiography case studies

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