practical cardiology case studies
DESCRIPTION
Practical Cardiology Case Studies. Wendy Blount, DVM Nacogdoches TX. Ginger. Signalment 12 year old SF cocker spaniel Chief complaint Several episodes of collapse during the past month Description matches partial seizure Rear legs get weak on walks Lethargic and dull in general. Ginger. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/1.jpg)
Practical CardiologyCase Studies
Wendy Blount DVMNacogdoches TX
Ginger
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
Ginger
Exambull Dark maroon oral mucous membranesbull Rear foot pads cyanotic (heart sounds)bull Split S2bull Neurologic exam normal except dull mental
status
Ginger
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
Ginger
Initial Diagnostic Planbull CBC GHP electrolytesbull Arterial blood gases Pulse oximetrybull ECGbull Thoracic radiographsBloodworkbull Tech couldnrsquot get enough serum for serologybull CBC ndash PCV 73bull GHP and electrolytes - normal
Ginger
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
Ginger
Arterial blood gasesbull pO2 ndash 52 mmHgbull pCO2 ndash 36 mmHgbull all else normal
Pulse oximetrybull Lip ndash O2 sat 89bull Vulva - O2 sat 67
Ginger
Ginger
Ginger
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
Ginger
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
Ginger
Ginger
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
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 2: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/2.jpg)
Ginger
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
Ginger
Exambull Dark maroon oral mucous membranesbull Rear foot pads cyanotic (heart sounds)bull Split S2bull Neurologic exam normal except dull mental
status
Ginger
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
Ginger
Initial Diagnostic Planbull CBC GHP electrolytesbull Arterial blood gases Pulse oximetrybull ECGbull Thoracic radiographsBloodworkbull Tech couldnrsquot get enough serum for serologybull CBC ndash PCV 73bull GHP and electrolytes - normal
Ginger
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
Ginger
Arterial blood gasesbull pO2 ndash 52 mmHgbull pCO2 ndash 36 mmHgbull all else normal
Pulse oximetrybull Lip ndash O2 sat 89bull Vulva - O2 sat 67
Ginger
Ginger
Ginger
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
Ginger
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
Ginger
Ginger
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
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 3: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/3.jpg)
Ginger
Exambull Dark maroon oral mucous membranesbull Rear foot pads cyanotic (heart sounds)bull Split S2bull Neurologic exam normal except dull mental
status
Ginger
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
Ginger
Initial Diagnostic Planbull CBC GHP electrolytesbull Arterial blood gases Pulse oximetrybull ECGbull Thoracic radiographsBloodworkbull Tech couldnrsquot get enough serum for serologybull CBC ndash PCV 73bull GHP and electrolytes - normal
Ginger
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
Ginger
Arterial blood gasesbull pO2 ndash 52 mmHgbull pCO2 ndash 36 mmHgbull all else normal
Pulse oximetrybull Lip ndash O2 sat 89bull Vulva - O2 sat 67
Ginger
Ginger
Ginger
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
Ginger
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
Ginger
Ginger
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
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 4: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/4.jpg)
Ginger
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
Ginger
Initial Diagnostic Planbull CBC GHP electrolytesbull Arterial blood gases Pulse oximetrybull ECGbull Thoracic radiographsBloodworkbull Tech couldnrsquot get enough serum for serologybull CBC ndash PCV 73bull GHP and electrolytes - normal
Ginger
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
Ginger
Arterial blood gasesbull pO2 ndash 52 mmHgbull pCO2 ndash 36 mmHgbull all else normal
Pulse oximetrybull Lip ndash O2 sat 89bull Vulva - O2 sat 67
Ginger
Ginger
Ginger
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
Ginger
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
Ginger
Ginger
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
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 5: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/5.jpg)
Ginger
Initial Diagnostic Planbull CBC GHP electrolytesbull Arterial blood gases Pulse oximetrybull ECGbull Thoracic radiographsBloodworkbull Tech couldnrsquot get enough serum for serologybull CBC ndash PCV 73bull GHP and electrolytes - normal
Ginger
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
Ginger
Arterial blood gasesbull pO2 ndash 52 mmHgbull pCO2 ndash 36 mmHgbull all else normal
Pulse oximetrybull Lip ndash O2 sat 89bull Vulva - O2 sat 67
Ginger
Ginger
Ginger
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
Ginger
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
Ginger
Ginger
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
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 6: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/6.jpg)
Ginger
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
Ginger
Arterial blood gasesbull pO2 ndash 52 mmHgbull pCO2 ndash 36 mmHgbull all else normal
Pulse oximetrybull Lip ndash O2 sat 89bull Vulva - O2 sat 67
Ginger
Ginger
Ginger
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
Ginger
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
Ginger
Ginger
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
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 7: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/7.jpg)
Ginger
Arterial blood gasesbull pO2 ndash 52 mmHgbull pCO2 ndash 36 mmHgbull all else normal
Pulse oximetrybull Lip ndash O2 sat 89bull Vulva - O2 sat 67
Ginger
Ginger
Ginger
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
Ginger
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
Ginger
Ginger
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
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 8: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/8.jpg)
Ginger
Ginger
Ginger
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
Ginger
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
Ginger
Ginger
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
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 9: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/9.jpg)
Ginger
Ginger
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
Ginger
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
Ginger
Ginger
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
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 10: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/10.jpg)
Ginger
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
Ginger
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
Ginger
Ginger
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
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 11: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/11.jpg)
Ginger
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
Ginger
Ginger
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
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 12: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/12.jpg)
Ginger
Ginger
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
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 13: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/13.jpg)
Ginger
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
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 14: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/14.jpg)
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 15: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/15.jpg)
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 16: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/16.jpg)
Ginger
Right to Left Shuntbull Reverse PDA (right to left)
ndash Eisenmeingerrsquos physiologybull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogram
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 17: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/17.jpg)
Ginger
Right to Left Shuntbull Reverse PDA (right to left)bull Tetralogy of Fallotbull AV fistula with pulmonary hypertensionEchocardiogrambull RV thickeningbull RV normally thinner than LVbull No PDA seen without Doppler
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 18: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/18.jpg)
Ginger
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 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 19: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/19.jpg)
Reverse 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
connectsbull 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 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 20: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/20.jpg)
Reverse 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 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 21: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/21.jpg)
Reverse 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 PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 22: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/22.jpg)
Reverse PDA
Prognosisbull Can do well short termbull Poor prognosis long term
ndash Survival months to a year or twobull Phlebotomy interval is progressively shorter
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 23: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/23.jpg)
Gabby
6 month female DSHPresented for OHE
PreAnesthetic Exam - HR 100
bull No other abnormal findings
bull Preanesthetic bloodwork normal
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 24: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/24.jpg)
Gabby
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
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 25: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/25.jpg)
Gabby
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
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 26: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/26.jpg)
Gabby
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 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 27: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/27.jpg)
3rd 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 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 28: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/28.jpg)
3rd 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 Dogs
50 mmsec
Pre-Operative ECGbull Atrial rate = 200 per minutebull Ventricular rate = 40 per minute
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 29: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/29.jpg)
3rd 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 Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 30: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/30.jpg)
3rd degree AV block in Dogs
Post-Operative ECGbull Ventricular rate = 100
50 mmsec
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 31: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/31.jpg)
Trip
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
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 32: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/32.jpg)
Trip
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
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 33: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/33.jpg)
Trip
Exambull 3 murmurs
1 PMI left base ndash To-and-fro murmur 36ndash aortic stenosis in systole regurg in diastole2 PMI left apex but heard all over chest ndash Holosystolic murmur 36 ndash Mitral regurgitation due to LHF3 PMI Carotid artery ndash 26 ejection murmurndash aortic stenosis
![Page 34: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/34.jpg)
Trip
Differential Diagnosesbull Aortic endocarditisbull SAS with aortic regurgitationbull Mitral regurgitation (endocarditis)
Diagnostic Planbull Thoracic radiographsbull EKGbull Echocardiography
Trip
EKGbull Normal sinus rhythm for 10 minutes
Trip
EKGbull Normal sinus rhythm for 10 minutes
Trip
EKGbull Normal sinus rhythm for 10 minutesThoracic 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 - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort Axis ndash LV PM
Trip - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort Axis ndash LV PM
Trip - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort 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 - 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 - 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 - 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 - Echo
Short Axis ndash PAbull No abnormalities notedLong Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities notedLong 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 - Echo
Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 35: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/35.jpg)
Trip
EKGbull Normal sinus rhythm for 10 minutes
Trip
EKGbull Normal sinus rhythm for 10 minutes
Trip
EKGbull Normal sinus rhythm for 10 minutesThoracic 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 - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort Axis ndash LV PM
Trip - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort Axis ndash LV PM
Trip - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort 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 - 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 - 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 - 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 - Echo
Short Axis ndash PAbull No abnormalities notedLong Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities notedLong 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 - Echo
Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 36: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/36.jpg)
Trip
EKGbull Normal sinus rhythm for 10 minutes
Trip
EKGbull Normal sinus rhythm for 10 minutesThoracic 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 - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort Axis ndash LV PM
Trip - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort Axis ndash LV PM
Trip - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort 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 - 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 - 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 - 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 - Echo
Short Axis ndash PAbull No abnormalities notedLong Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities notedLong 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 - Echo
Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 37: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/37.jpg)
Trip
EKGbull Normal sinus rhythm for 10 minutesThoracic 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 - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort Axis ndash LV PM
Trip - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort Axis ndash LV PM
Trip - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort 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 - 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 - 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 - 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 - Echo
Short Axis ndash PAbull No abnormalities notedLong Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities notedLong 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 - Echo
Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 38: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/38.jpg)
Trip - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort Axis ndash LV PM
Trip - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort Axis ndash LV PM
Trip - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort 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 - 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 - 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 - 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 - Echo
Short Axis ndash PAbull No abnormalities notedLong Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities notedLong 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 - Echo
Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 39: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/39.jpg)
Trip - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort Axis ndash LV PM
Trip - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort 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 - 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 - 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 - 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 - Echo
Short Axis ndash PAbull No abnormalities notedLong Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities notedLong 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 - Echo
Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 40: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/40.jpg)
Trip - Echo
Short Axis ndash LV Apexbull No abnormalities notedShort 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 - 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 - 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 - 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 - Echo
Short Axis ndash PAbull No abnormalities notedLong Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities notedLong 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 - Echo
Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 41: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/41.jpg)
Trip - 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 - 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 - 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 - Echo
Short Axis ndash PAbull No abnormalities notedLong Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities notedLong 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 - Echo
Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 42: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/42.jpg)
Trip - 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 - 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 - Echo
Short Axis ndash PAbull No abnormalities notedLong Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities notedLong 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 - Echo
Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 43: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/43.jpg)
Trip - 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 - Echo
Short Axis ndash PAbull No abnormalities notedLong Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities notedLong 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 - Echo
Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 44: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/44.jpg)
Trip - Echo
Short Axis ndash PAbull No abnormalities notedLong Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities notedLong 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 - Echo
Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 45: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/45.jpg)
Trip - Echo
Short Axis ndash PAbull No abnormalities noted
Long Axis ndash 4 Chamber
Trip - Echo
Short Axis ndash PAbull No abnormalities notedLong 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 - Echo
Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 46: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/46.jpg)
Trip - Echo
Short Axis ndash PAbull No abnormalities notedLong 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 - Echo
Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 47: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/47.jpg)
Trip - Echo
Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
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Trip - Echo
Long Axis ndash LVOT (video)bull Hyperechoic thickened mitral valve leaflets
Diagnosisbull Aortic endocarditis
Therapeutic Planbull Elected euthanasia due to poor prognosis
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 49: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/49.jpg)
Trip
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 50: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/50.jpg)
Valvular 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 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 51: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/51.jpg)
Valvular 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 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 52: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/52.jpg)
Valvular 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 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 53: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/53.jpg)
Valvular 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 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 54: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/54.jpg)
Valvular 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 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 55: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/55.jpg)
Valvular 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 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 56: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/56.jpg)
Valvular 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)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 57: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/57.jpg)
Maximus
18 month old male BoxerChief 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
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 58: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/58.jpg)
Maximus
Diagnosticsbull Blood culture
ndash negative (2 samples 2 hours apart)bull Urine culture
ndash Enterobacter susceptible to allbull CBC
ndash neutrophilia 23100ulndash Mild anemia ndash PCV 355
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 59: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/59.jpg)
Maximus
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
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 60: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/60.jpg)
Maximus
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
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 61: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/61.jpg)
Maximus
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
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 62: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/62.jpg)
Maximus
Diagnostics ndash Day 5 ndash RR 36 BP 150bull Chest x-rays - No changebull BUN ndash 43bull Electrolytes - normalTreatment 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
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 63: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/63.jpg)
Maximus
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
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 64: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/64.jpg)
Ike
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
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 65: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/65.jpg)
Ike
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
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 66: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/66.jpg)
Ike
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)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 67: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/67.jpg)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 68: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/68.jpg)
Ike
Diagnosticsbull Chest x-rays
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 69: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/69.jpg)
Ike
Diagnosticsbull Chest x-rays
ndash Elevated trachea (heart enlargement)ndash Generalized cardiomegaly ndash VHS 9ndash Distended caudal vena cavandash Hepatomegalyndash Ascites
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 70: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/70.jpg)
Ike
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
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 71: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/71.jpg)
Ike
DDx Hypoalbuminemiabull Liver diseasebull PLNbull PLE unlikely with no clinical signsbull Sequestration in ascites
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 72: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/72.jpg)
Ike
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
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 73: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/73.jpg)
Ike
Recheck Scheduled for 1 weekbull Echocardiogrambull Electrolytesbull Abdominal USbull UPCbull bile acidsbull Fluid analysis if ascites fails to resolve
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 74: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/74.jpg)
Ike
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
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 75: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/75.jpg)
Ike
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 - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 76: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/76.jpg)
Ike - Echo
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 77: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/77.jpg)
Ike - Echo
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 78: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/78.jpg)
Ike - 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 - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 79: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/79.jpg)
Ike - 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 - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 80: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/80.jpg)
Ike - Echo
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 81: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/81.jpg)
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 82: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/82.jpg)
Ike - Echo
Short Axis ndash LV MVbull EPSS ndash 2 mm
Short Axis ndash LARVOT
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 83: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/83.jpg)
Ike - 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 - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 84: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/84.jpg)
Ike - Echo
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 85: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/85.jpg)
Ike - Echo
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 86: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/86.jpg)
Ike - Echo
Short Axis ndash PAbull Enlarged main pulmonary arterybull RV enlarged
Long Axis ndash 4 Chamberbull No apparent enlargement of LAbull LV thickened
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 87: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/87.jpg)
Ike - Echo
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 88: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/88.jpg)
Ike - Echo
Long Axis ndash LVOTbull No apparent enlargement of LAbull LV thickened
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 89: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/89.jpg)
Ike - 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 - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 90: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/90.jpg)
Ike - 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 - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 91: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/91.jpg)
Ike - 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 - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 92: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/92.jpg)
Ike - 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 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 93: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/93.jpg)
Pericardial 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 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 94: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/94.jpg)
Pericardial 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 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 95: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/95.jpg)
Pericardial 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 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 96: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/96.jpg)
Pericardial 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 Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 97: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/97.jpg)
Pericardial Effusion
Video Pericardial EffusionVideo Pleural Effusion
Video Consolidated Lung LobeVideo Normal thorax
Video Mediastinal Mass
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 98: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/98.jpg)
Taz
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
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 99: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/99.jpg)
Taz
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
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 100: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/100.jpg)
Taz
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 101: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/101.jpg)
Taz
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 102: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/102.jpg)
Taz
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 normalPT PTT ACTbull normal
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 103: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/103.jpg)
Taz
Abdominal USbull NormalSent pericardial fluid for culture and sensitivityEmergency 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
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 104: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/104.jpg)
Taz
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
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 105: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/105.jpg)
Taz
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 Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 106: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/106.jpg)
Cardiac Masses
DDxbull Chemodectomabull HSAbull Myxosarcomabull Ectopic thyroid carcinomabull Mesotheliomabull LSAbull fibrosarcoma
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 107: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/107.jpg)
Cardiac 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
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 108: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/108.jpg)
Hank
Signalmentbull 10 week old male schnauzer
Chief Complaintbull Loud heart murmur heard on examination for routine
vaccinationsbull Suspect congenital heart defect
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 109: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/109.jpg)
Hank
Exambull mm pink CRT 2 secbull 46 ejection murmur loudest at left heart basebull Mild superficial pyoderma
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 110: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/110.jpg)
Hank
Initial Differential Diagnosesbull Pulmonic stenosisbull Aortic Stenosis
Initial Diagnostic Planbull Chest x-raysbull EKGbull Echocardiogram
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 111: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/111.jpg)
Hank
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 112: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/112.jpg)
Hank
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 113: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/113.jpg)
Hank
Thoracic radiographsbull Dorsally elevated tracheabull Vertebral heart score 95bull Right heart enlargementbull Right auricularatrial enlargementbull Distended caudal vena cavabull Bulge at main pulmonary artery
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 114: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/114.jpg)
Hank
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 - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 115: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/115.jpg)
Hank - Echo
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 116: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/116.jpg)
Hank - 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 - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 117: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/117.jpg)
Hank - Echo
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 118: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/118.jpg)
Hank - 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 - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 119: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/119.jpg)
Hank - Echo
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 120: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/120.jpg)
Hank - 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 - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 121: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/121.jpg)
Hank - 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 Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 122: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/122.jpg)
Pulmonic Stenosis
Clinical featuresbull Many breed predispositions
ndash Bulldog chihuahua Beagle Cavalierbull 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 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 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 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)
-
![Page 123: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/123.jpg)
Pulmonic 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 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 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)
-
![Page 124: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/124.jpg)
Pulmonic 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 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)
-
![Page 125: Practical Cardiology Case Studies](https://reader035.vdocument.in/reader035/viewer/2022062310/56816637550346895dd9a54b/html5/thumbnails/125.jpg)
Pulmonic 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)
-