Basic Echocardiography Case Studies

1
Basic EchocardiographyCase Studies

• Wendy Blount, DVM
• Nacogdoches TX

2
Trip

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

3
Trip

• Exam
• T 102.2, P 168, R 42, CRT 3 sec, BCS 2.5, BP 100
• 3 murmurs
• To-and-fro murmur, 3/6, PMI left base
• Holosystolic murmur 3/6 over rest of chest
• 2/6 ejection murmur PMI Carotid
• Bounding pulses, notable in small arteries
• Precordial exaggerated left apical heave
• Lung sounds clear

4
Trip

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

5
Trip

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

6
Trip - Echo

• Short Axis LV Apex
• No abnormalities noted
• Short Axis LV PM
• LVIDD 57.3 (n 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 gt70)

7
Trip - Echo

• Short Axis MV
• EPSS 8 mm (n 0-6)
• Short Axis Ao/RVOT
• AoS 20.2 (normal)
• LAD 27.8 (n 19.0-20.5)
• LA/Ao 27.8/20.2 1.38 (n 0.8-1.3)
• Aortic valve leaflets are hyperechoic

8
Trip - Echo

• Short Axis PA
• No abnormalities noted
• Long Axis 4 Chamber
• LA appeared mildly enlarged
• IVS bowed anteriorly toward RV
• No evidence of mitral encodarditis or
  endocardiosis

9
Trip - Echo

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

10
Valvular Endocarditis

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

11
Valvular Endocarditis

• Echocardiographic abnormalities
• Thickened, hyperechoic valves
• Vegetation may flop around
• MV in diastole, AV in systole
• Variable LV dilation (more with time)
• FS normal to low normal until myocardial failure
• MV endocarditis can be difficult to distinguish
  from MV endocardiosis
• Endocarditis dogs are systemically ill

12
Valvular Endocarditis

• Treatment
• Based on urine and blood culture and sensitivity
• Antibiotics
• IV 3-5 days broad spectrum until culture
  results
• SC/IM 35 days
• Then PO long term often for life
• Treat Heart failure (severe)
• Treat ventricular arrhythmia if present
• Watch for and treat bacterial embolization of
  abdominal organs, skin, IVDiscs, CNS, joints, etc.

13
Valvular Endocarditis

• Video

14
Maximus

• 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

15
Maximus

• 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

16
Maximus

• 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)

17
Maximus

• 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

18
Maximus

• Treatment Day 3 RR 30
• Chest x-rays
• Pulmonary edema much improved, but mild amount
  still present
• Furosemide - 75 mg PO BID
• Enalapril 15 mg PO BID
• Added Spironolactone 25 mg PO BID

19
Maximus

• Diagnostics Day 5 RR 36, BP 150
• Chest x-rays - No change
• BUN 43
• Electrolytes - normal
• Treatment Day 5
• Furosemide - 75 mg PO BID
• Enalapril 15 mg PO BID
• Spironolactone increased to 50 mg PO BID
• Added Hydralazine 12.5 mg PO BID

20
Maximus

• Diagnostics Day 10
• RR 30, BP 135, Wt 61.8, Temp 103
• Chest x-rays perihilar edema resolved
• BUN 11, albumin 2.3
• Electrolytes normal
• CBC neutrophilia 23,000/ul
• Continued this treatment for the rest of Maxs
  life 3 months

21
Ike

• Signalment
• 7 year old castrated male Persian cat
• Chief Complaint
• Recurring anemia
• Episodes of weakness, anorexia, dullness and
  salivation
• Constipation often associated with episodes
• Tremendous hair loss and 2 lb weight loss over 6
  months

22
Ike

• Exam T 100.3, P 180, R 40, BP 135
• Fleas
• Gallop rhythm, followed by normal heart sounds,
  followed by 2/6 systolic murmur
• Hepatomegaly and mild to moderate ascites
• Jugular vein distension
• Did not do hepatojugular reflux test
• Tongue protrudes and tip is dry
• Breathes with mouth open when stressed

23
Ike

• Diagnostics
• CBC normal
• FeLV/FIV negative
• GHP/electrolytes
• ALT 218 (n 10-100)
• Bili 0.3 (high normal)
• Albumin 1.7 (n 2.3-3.4)
• K 2.5 (n 2.9-4.2)

24
Ike

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

25
Ike

• Diagnostics
• Diagnosis - Right heart failure with cardiomegaly
• DDx cardiomegaly
• Diaphragmatic hernia
• pericardial effusion
• heart enlargement
• HCM, DCM, RCM
• VSD
• Valvular disease
• Hypoalbuminemia/liver disease may be contributing
  to ascites

26
Ike

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

27
Ike

• Initial Treatment
• No echo done because Ike became dyspneic after
  chest rads
• Furosemide 5 mg PO BID (wt 5 lbs 7 oz)
• Potassium gluconate 2 mEq PO SID
• Metronidazole 625 mg PO SID x 2 weeks

28
Ike

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

29
Ike

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

30
Ike

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

31
Ike - Echo

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

32
Ike - Echo

• Short Axis LV PM
• IVSTD 10.2 (n 3-6)
• LVIDD 14.1 (n 10-21)
• LVPWD 6.95 (n 3-6)
• IVSTS 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

33
Ike - Echo

• Short Axis LV MV
• EPSS 2 mm
• Short Axis LA/RVOT
• RVOT looks subjectively enlarged
• LA and LA normal
• LA/Ao 11.1/8.8 1.26 (normal)

34
Ike - Echo

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

35
Ike - Echo

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

36
Ike - Echo

• Abdominal US
• No fluid present in the abdomen
• Main bile duct tortuous
• Pancreas normal
• Did not do liver aspirate because Ike would not
  tolerate it without general anesthesia

37
Ike - Echo

• Treatment - Update
• Finish metronidazole, then start milk thistle
• Increase Kgluconate to 2 mEq PO BID
• Continue furosemide 5 mg PO BID
• Add enalapril 1.25 mg PO SID
• Recheck BUN/lytes 5 days
• If OK, inrease to BID
• Recheck BUN/lytes 5 days
• Laxatone PRN for constipation
• Recheck echo, chest rads in 6 months or sooner if
  RR gt 40 at rest

38
Pericardial 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

39
Pericardial Effusion

• Echocardiographic Abnormalities
• Careful not to confuse pericardial fat with
  pericardial effusion
• Look at relative echogenicity
• Careful not to confuse normal anechoic structures
  with pericardial effusion
• Descending aorta
• Enlarged left auricle

40
Pericardial Effusion

• Echocardiographic Abnormalities
• Careful to distinguish pericardial from pleural
  effusion
• Pericardium not visualized with pleural effusion
• Collapsed lung lobes may be seen with pleural
  effusion (look like liver)
• Careful not to confuse with liver in a
  peritineopericardial diaphragmatic hernia
• Heart my swing back forth in the pericardium

41
Pericardial Effusion

• Echocardiographic Abnormalities
• Cardiac tamponade
• Compression of RV
• Diastolic collapse of RV
• IVS may be flattened with paradoxical motion
• Pericardiocentsis is imperative
• Aggressive diuresis will reduce preload
• Evaluation of heart base tumor prior to
  pericardiocentesis will be more thorough

42
Pericardial Effusion

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

43
Hank

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

44
Hank

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

45
Hank

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

46
Hank

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

47
Hank

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

48
Hank

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

49
Hank - Echo

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

50
Hank - Echo

• Short Axis PA
• MPA dilated
• RV as thick as LV markedly thickened
• Long Axis 4 Chamber
• Aberrant septum dividing RA into 2 chambers
  cranial and caudal
• Long Axis LVOT
• RV as thick as LV markedly thickened

51
Hank - Echo

• Diagnosis
• Likely Pulmonic Stenosis
• DDx RV thickening
• Need Doppler to confirm, and to determine
  gradient
• Cor triatriatum dexter
• Plan updated
• Referral to TAMU for ballon valvuloplasty
• Atenolol 0.5 mg/kg PO BID (monitor weight to
  increased dose PRN until cath procedure)

52
Hank - Echo

• Diagnosis
• Likely Pulmonic Stenosis
• DDx RV thickening
• Heartworms impossible in a 10 week old puppy
• Pulmonary hypertension rare in a 10 week old
  puppy
• Need Doppler to confirm, and to determine
  gradient
• Cor triatriatum dexter

53
Hank - Echo

• Plan updated
• Referral to TAMU for ballon valvuloplasty
• Atenolol 0.5 mg/kg PO BID (monitor weight to
  increased dose PRN until cath procedure)

54
Pulmonic Stenosis

• Clinical features
• Many breed predispositions
• Bulldog, chihuahua, Beagle, Cavalier
• Often valvular and subvalvular
• Valvular defect can be corrected by valvuloplasty
• Prognosis varies, depending on severity
• Mild less than 50 mm Hg gradient
• Moderate 50-100 mm Hg
• Severe - gt100 mm Hg
• Can be progressive

55
Pulmonic Stenosis

• Clinical features
• Bulldogs can have left coronary artery anomaly,
  which can preclude balloon valvuloplasty
• Arrhythmia is much more common than RHF
• May be part of Tetralogy of Fallot
• PS
• RV hypertrophy
• VSD
• Overriding aorta

56
Pulmonic Stenosis

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