Transcript Name of presentation

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
Exam
• Dark maroon oral mucous membranes
• Rear foot pads cyanotic (heart sounds)
• Split S2
• Neurologic exam normal, except dull mental
status
Ginger
Differential Diagnosis – Split S2
• Pulmonic and aortic valves don’t close at the same time
– Pulmonary hypertension
– Normal variation in giant dogs
– Reverse PDA
Differential Diagnosis - cyanosis
• Respiratory hypoxia
• Cardiac hypoxia
Ginger
Initial Diagnostic Plan
• CBC, GHP, electrolytes
• Arterial blood gases, Pulse oximetry
• ECG
• Thoracic radiographs
Bloodwork
• Tech couldn’t get enough serum for serology
• CBC – PCV 73%
• GHP and electrolytes - normal
Ginger
DDx Differential Cyanosis
• FATE – Femoral Artery ThromboEmbolism
– Lack of femoral pulses
– Feet cool to the touch
• Right to Left shunt – ductus is distal to the
brachiocephalic trunk
– Reverse PDA
– AV fistula with pulmonary hypertension
– Tetralogy of Fallot
Ginger
Arterial blood gases
• pO2 – 52 mmHg
• pCO2 – 36 mmHg
• all else normal
Pulse oximetry
• Lip – O2 sat 89%
• Vulva - O2 sat 67%
Ginger
Ginger
Ginger
Thoracic radiographs
• Normal great vessels
• Normal heart size (VHS 9.5)
• aortic bulge on VD
• No evidence of severe respiratory disease
which might cause hypoxia
• No evidence of heart failure
Ginger
ECG
• S wave mildly deep in leads I,, II, III, aVF
• MEA 90o
• Arrhythmia doesn’t seem likely
Differential Diagnoses
• Right to left shunt
• Pulmonary hypertension
Ginger
Ginger
ECG
• S wave mildly deep in leads II, III, aVF
• MEA 90o
• Arrhythmia doesn’t seem likely
Differential Diagnoses
• Right to left shunt
• Pulmonary hypertension
Ginger
Right to Left Shunt
• Reverse PDA (right to left)
– Eisenmeinger’s physiology
• Tetralogy of Fallot
• AV fistula with pulmonary hypertension
Echocardiogram
Ginger
Right to Left Shunt
• Reverse PDA (right to left)
– Eisenmeinger’s physiology
• Tetralogy of Fallot
• AV fistula with pulmonary hypertension
Echocardiogram
Ginger
Right to Left Shunt
• Reverse PDA (right to left)
– Eisenmeinger’s physiology
• Tetralogy of Fallot
• AV fistula with pulmonary hypertension
Echocardiogram
Ginger
Right to Left Shunt
• Reverse PDA (right to left)
• Tetralogy of Fallot
• AV fistula with pulmonary hypertension
Echocardiogram
• RV thickening
• RV normally thinner than LV
• No PDA seen without Doppler
Ginger
Bubble Study
• Place venous catheter
• Shake 5-10 cc saline vigorously
• Place US probe where you can look for shunting
– Long 4 chamber view
– Abdominal aorta
• Inject IV quickly
• Bubbles normally appear on the right (video)
• Watch for bubbles on the left (this means R to L shunt)
• False negatives when bubbles disperse quickly
Reverse PDA
• Reverse PDAs are usually large, providing no resistance
to blood flow
– Ductus is often as large in diameter as the great vessels it
connects
• increase in pulmonary artery pressure combined with the
increase in pulmonary blood flow creates pathologic
responses in the pulmonary arteries over time
• a continuous murmur is heard during the first days to
weeks of life but disappears before the eighth week
• Often do well until polycythemia develops late in life
Reverse PDA
Treatment
• Ligation of right to left shunting PDA results in death
due to pulmonary hypertension
– Has been ligated in stages without causing death
– Cyanosis and symptoms usually persist
• Managed Medically by periodic phlebotomy
–
–
–
–
–
Remove 10 ml/lb and replace with IV fluids
Eliminate hyperviscosity without inducing hypoxia
Goal for PCV is 60-65%
Excellent blood for RBC transfusion ;-)
Repeat when clinical signs return
Reverse PDA
Treatment
• Hydroxyurea
– 30 mg/kg/day for 7 to 10 days followed by 15
mg/kg/day.
– CBC q1-2 weeks
– D/C when Bone marrow suppression
– Resume lower dose
– Some dogs require higher doses
– side effects – GI and sloughing of the nails
Reverse PDA
Prognosis
• Can do well short term
• Poor prognosis long term
– Survival months to a year or two
• Phlebotomy interval is progressively shorter
Gabby
6 month female DSH
Presented for OHE
PreAnesthetic Exam HR 100
• No other abnormal
findings
• Preanesthetic bloodwork
normal
Gabby
Pre-Anesthetic ECG
20mm = 1 mV
25 mm/sec
• Heart rate
– P rate is 160 bpm, QRS rate is 100 bpm
• Rhythm
3rd Degree AV
block
– no consistent PR interval
– P and QRS complexes are disassociated, but each regular
Gabby
• Gabby was not spayed at 6 months of age
• When she reached 7 years of age, she had her 4th litter
• She was referred to Drs. Miller and Gordon at TAMU for
spay
– When induced, her heart rate immediately fell to 40 and was
progressively dropping
– A temporary pacemaker was placed
– Gabby was spayed and recovered uneventfully
– 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.
It’s your fault.
Love, Gabby
3rd degree AV block
3rd Degree AV block is the most common cause
of bradycardia in the cat
Treatment- cats
• Often no treatment needed for cats
– AV node pacemaker is 100 per minute
– AV node pacemaker is 40-60 per minute in the dog
• Cats do well unless they undergo anesthesia
• Avoid drugs that increase vagal tone
– Alpha blockers – Dexdomitor, Rompun
3rd degree AV block in Dogs
•
•
•
•
Usually presents for syncope (HR 20-40 per minute)
“Cannon wave” jugular pulses (bradycardia)
Treated with pacemaker implantation
Drug therapy not usually successful
– Usually no response to atropine
– Atropine often makes 2nd degree block go away
– Some have tried theophylline
• Prognosis poor without pacemaker
• If lactate is high, emergency pacemaker is needed
3rd degree AV block in Dogs
Pre-Operative ECG
• Atrial rate = 200 per minute
• Ventricular rate = 40 per minute
50 mm/sec
3rd degree AV block in Dogs
Post-Operative ECG
• Ventricular rate = 100
50 mm/sec
Trip
Signalment
• 2 year old castrated male border collie
Chief Complaint/History
• Productive Cough, weight loss for 2 months
• Breathing hard for a 2 days
• Energy good; did well in agility 4 days ago
• Owner thinks has had lifelong PU-PD
• Has wanted to be in AC this summer – unlike
last summer when he enjoyed being outside
Trip
Exam
• T 102.2, P 168, R 42, CRT 3 sec
• BCS 2.5
• BP 100
• Bounding pulses, notable in dorsal pedal artery
• Precordial – exaggerated left apical heave
• Lung sounds clear
Trip
Exam
• 3 murmurs:
1. PMI left base
– To-and-fro murmur 3/6
– aortic stenosis in systole, regurg in diastole
2. PMI left apex, but heard all over chest
– Holosystolic murmur 3/6
– Mitral regurgitation due to LHF
3. PMI Carotid artery
– 2/6 ejection murmur
– aortic stenosis
Trip
Differential Diagnoses
• Aortic endocarditis
• SAS with aortic regurgitation
• Mitral regurgitation (endocarditis?)
Diagnostic Plan
• Thoracic radiographs
• EKG
• Echocardiography
Trip
EKG
• Normal sinus rhythm for 10 minutes
Trip
EKG
• Normal sinus rhythm for 10 minutes
Trip
EKG
• Normal sinus rhythm for 10 minutes
Thoracic Radiographs
• Interstitial pattern caudal lung fields
• Vertebral heart score 10.5
• Enlarged cranial pulmonary lobar vein
• Mildly enlarged left atrium
• Early left congestive heart failure
Trip - Echo
Short Axis – LV Apex
• No abnormalities noted
Short Axis – LV PM
Trip - Echo
Short Axis – LV Apex
• No abnormalities noted
Short Axis – LV PM
Trip - Echo
Short Axis – LV Apex
• No abnormalities noted
Short Axis – LV PM
• LVIDD – 57.3 (n 31.3-34)
• IVSTS – 15.5 mm (n 12.6-13.7)
• LVIDS – 41.1 mm (18.8-20.7)
• FS = (57.3-41.1)/57.3 = 28% (n 30-46%)
• EF = 54% (n >70%)
Trip - Echo
Short Axis – MV
• EPSS – 8 mm (n 0-6)
Short Axis – Ao/RVOT
• AoS – 20.2 (normal)
• LAD – 27.8 (n 19.0-20.5)
• LA/Ao – 27.8/20.2 = 1.38 (n 0.8-1.3)
• Aortic valve leaflets are hyperechoic
Trip - Echo
Short Axis – MV
• EPSS – 8 mm (n 0-6)
Short Axis – Ao/RVOT
• AoS – 20.2 (normal)
• LAD – 27.8 (n 19.0-20.5)
• LA/Ao – 27.8/20.2 = 1.38 (n 0.8-1.3)
• Aortic valve leaflets are hyperechoic
Trip - Echo
Short Axis – MV
• EPSS – 8 mm (n 0-6)
Short Axis – Ao/RVOT
• AoS – 20.2 (normal)
• LAD – 27.8 (n 19.0-20.5)
• LA/Ao – 27.8/20.2 = 1.38 (n 0.8-1.3)
• Aortic valve leaflets are hyperechoic
Trip - Echo
Short Axis – PA
• No abnormalities noted
Long Axis – 4 Chamber
Trip - Echo
Short Axis – PA
• No abnormalities noted
Long Axis – 4 Chamber
Trip - Echo
Short Axis – PA
• No abnormalities noted
Long Axis – 4 Chamber
• LA appeared mildly enlarged
• IVS bowed anteriorly toward RV
• No evidence of mitral encodarditis or
endocardiosis
• Vegetation on aortic valve
Trip - Echo
Trip - Echo
Long Axis – LVOT
(video)
• Hyperechoic thickened mitral valve leaflets
Diagnosis
• Aortic endocarditis
Therapeutic Plan
• Elected euthanasia due to poor prognosis
Trip
Valvular Endocarditis
Clinical Features
• Present for FUO, weight loss or heart failure
• Aortic much more common than mitral
• Dogs much more common than cats
• Many bacteria including Bartonella
• Breed predisposition
– Rottweiler, Boxer, Golden retriever
– Newfoundland, German shepard
Valvular Endocarditis
Clinical Features
• Abnormal valve + bacteremia = endocarditis
• Bacteremia caused routinely by:
–
–
–
–
–
–
Dental cleaning
Brushing your teeth (chewing)
Constipation, any GI illness
defecation
Urinary catheterization
infection
Valvular Endocarditis
ECG abnormalities
• Tall, wide P wave (LA enlargement)
• Tall R wave (LV enlargement)
• Ventricular arrhythmias common
– Treat if multiform of >30 per minute
– Class I or III antiarrhythmic
– Sotalol 2-3 mg/kg PO BID
Thoracic radiographs
• Left heart failure
Valvular Endocarditis
ECG abnormalities
• Tall, wide P wave (LA enlargement)
• Tall R wave (LV enlargement)
• Ventricular arrhythmias common
– Treat if multiform of >30 per minute
– Class I or III antiarrhythmic
– Sotalol 2-3 mg/kg PO BID
Thoracic radiographs
• Left heart failure
Valvular Endocarditis
Echocardiographic abnormalities
• Thickened, hyperechoic valves
• Vegetation may flop around
– MV in diastole, AV in systole
• Variable LV dilation (more with time)
• FS normal to low normal until myocardial failure
• MV endocarditis can be difficult to distinguish
from MV endocardiosis
– Endocarditis dogs are systemically ill
Valvular Endocarditis
Treatment
• Based on urine and blood culture and sensitivity,
Bartonella PCR
• Antibiotics
– IV 3-5 days – broad spectrum until culture results
– SC/IM 3-5 days
– Then PO long term – often for life
• Treat Heart failure (severe)
• Treat ventricular arrhythmia if present
• Watch for and treat bacterial embolization of abdominal
organs, skin, IVDiscs, CNS, joints, etc.
• Watch for and treat immune complex disease
Valvular Endocarditis
Prognosis
• <20% survival
• Antibiotic therapy often required for life
• Median survival is 6 days from diagnosis for aortic
endocarditis
• Survival is longer for mitral endocarditis
– LHF due to MR not as severe as AoR
(Client Handout)
Maximus
18 month old male Boxer
Chief Complaint
• Drastic and rapid weight loss
• Not eating well
• Coughing up blood tinged fluid since yesterday
Exam, Chest rads, ECG
• Similar to Trip, except temp 103.8
• And BCS 2
Maximus
Diagnostics
• Blood culture
– negative (2 samples 2 hours apart)
• Urine culture
– Enterobacter susceptible to all
• CBC
– neutrophilia 23,100/ul
– Mild anemia – PCV 35.5%
Maximus
Diagnostics
• General Health Profile, electrolytes
– BUN – 55 (n 10-29)
– ALT – 225 (n 10-120)
– Albumin – 2.2 (n 2.3-3.7)
• Urinalysis
– USG – 1.045
– WBC 7-10/hpf, rare bacteria seen
Maximus
Treatment (58 lbs, BCS 2, RR 66)
• Antibiotics
– IV - ampicillin 750 mg TID, Baytril 150 mg BID x 3 days
– IM – ampicillin 750 mg BID, Baytril 150 mg x 3 days
– PO – ampicillin 750 mg BID, Baytril 136 mg PO for life
• Furosemide
– 100 mg IV TID the first day - RR down to 28
– Then 75 mg PO BID
• Enalapril – 15 mg PO BID
Maximus
Treatment – Day 3 – RR 30, eating well
• Chest x-rays
– Pulmonary edema much improved, but mild amount
still present
• Furosemide - 75 mg PO BID
• Enalapril – 15 mg PO BID
• Added Spironolactone – 25 mg PO BID
Maximus
Diagnostics – Day 5 – RR 36, BP 150
• Chest x-rays - No change
• BUN – 43
• Electrolytes - normal
Treatment – Day 5
• Furosemide - 75 mg PO BID
• Enalapril – 15 mg PO BID
• Spironolactone – increased to 50 mg PO BID
• Added Hydralazine – 12.5 mg PO BID
Maximus
Diagnostics – Day 10
RR 30, BP 135, Wt 61.8, Temp 103
• Chest x-rays – perihilar edema resolved
• BUN – 11, albumin 2.3
• Electrolytes – normal
• CBC – neutrophilia 23,000/ul
Continued this treatment for the rest of Max’s
life – 3 months
Ike
Signalment
• 7 year old castrated male Persian cat
Chief Complaint
• Recurring anemia
• Episodes of weakness, anorexia, dullness and
salivation
• Constipation often associated with episodes
• Tremendous hair loss and 2 lb weight loss over 6
months
Ike
Exam – T 100.3, P 180, R 40, BP 135
• Fleas++++
• Gallop rhythm, followed by normal heart
sounds, followed by 2/6 systolic murmur
• Hepatomegaly and mild to moderate ascites
• Jugular vein distension
• Did not do hepatojugular reflux test
• Tongue protrudes and tip is dry
• Breathes with mouth open when stressed
Ike
Diagnostics
• CBC – normal
• FeLV/FIV – negative
• GHP/electrolytes –
–
–
–
–
ALT – 218 (n 10-100)
Bili – 0.3 (high normal)
Albumin 1.7 (n 2.3-3.4)
K – 2.5 (n 2.9-4.2)
Ike
Diagnostics
• Chest x-rays
Ike
Diagnostics
• Chest x-rays
Ike
Diagnostics
• Chest x-rays
–
–
–
–
–
Elevated trachea (heart enlargement)
Generalized cardiomegaly – VHS 9
Distended caudal vena cava
Hepatomegaly
Ascites
Ike
Diagnostics
• Diagnosis - Right heart failure with cardiomegaly
• DDx – cardiomegaly
– Diaphragmatic hernia
– pericardial effusion
– heart enlargement
• HCM, DCM, RCM
• VSD
• Valvular disease
– Hypoalbuminemia/liver disease may be contributing to ascites
Ike
DDx Hypoalbuminemia
• Liver disease
• PLN
• PLE unlikely with no clinical signs
• Sequestration in ascites
Ike
Initial Treatment
• No echo done because Ike became dyspneic
after chest rads
• Furosemide 5 mg PO BID (wt 5 lbs 7 oz)
• Potassium gluconate 2 mEq PO SID
• Metronidazole 625 mg PO SID x 2 weeks
Ike
Recheck Scheduled for 1 week
• Echocardiogram
• Electrolytes
• Abdominal US
• UPC
• bile acids
• Fluid analysis if ascites fails to resolve
Ike
Recheck – 1 week - Exam
• Ike tremendously improved
• Weight gain of 5 ounces
• Ascites has resolved
• Hepatomegaly no longer present
• P 160, RR 28, BP 110
• Haircoat seems improved
• 2/6 systolic murmur loudest at the sternum
• No open mouth breathing or inc RR when stressed
Ike
Recheck – 1 week - Diagnostics
• Electrolytes – K 2.7
• Albumin - 2.4 (normal)
• ALT - 134 (n 10-100)
• Bili - 0.3
• UPC – 0.5
• Bile Acids (fasting) - 157
Ike - Echo
Ike - Echo
Ike - Echo
Short Axis – LV Apex
• Mild pericardial effusion
Short Axis – LV PM
• Mild pericardial effusion
• LV subjectively thick
• Papillary muscles really big
• No evidence of pericardial hernia
Ike - Echo
Short Axis – LV PM
Dx – Hypertrophic
• IVSTD – 10.2 (n 3-6)
Cardiomyopathy
• LVIDD – 14.1 (n 10-21)
• LVPWD – 6.95 (n 3-6)
• IVSTS – 14.85 (4-9)
• LVIDS – 3.5 (n 4-10)
• LVPWS – 9.6 (n 4-11)
• FS – (14.1-3.5)/14.1 = 74.5% EF = 98%
Ike - Echo
Ike - Echo
Short Axis – LV MV
• EPSS – 2 mm
Short Axis – LA/RVOT
Ike - Echo
Short Axis – LV MV
• EPSS – 2 mm
Short Axis – LA/RVOT
Ike - Echo
Short Axis – LV MV
• EPSS – 2 mm
Short Axis – LA/RVOT
• RVOT looks subjectively enlarged
• LA and LA normal
• LA/Ao = 11.1/8.8 = 1.26 (normal)
Ike - Echo
Ike - Echo
Ike - Echo
Short Axis – PA
• Enlarged main pulmonary artery
• RV enlarged
Long Axis – 4 Chamber
• No apparent enlargement of LA
• LV thickened
Ike - Echo
Ike - Echo
Long Axis – LVOT
• No apparent enlargement of LA
• LV thickened
Ike - Echo
Abdominal US
• No fluid present in the abdomen
• Main bile duct tortuous
• Pancreas normal
• Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - Echo
Abdominal US
• No fluid present in the abdomen
• Main bile duct tortuous
• Pancreas normal
• Did not do liver aspirate because Ike would not
tolerate it without general anesthesia
Ike - Echo
Assessment
• Hypertrophic Cardiomyopathy
– Biventricular failure
– Secondary pericardial effusion, ascites, hepatomegaly
• Enlarged Pulmonary artery of unknown cause (DDx)
– Heartworm disease
– Pulmonary hypertension
• Liver Dysfunction of unknown cause
– Probable history of pancreatitis
– Possibly contributed to by passive congestion of RHF
• Financial Resources for Ike’s Diagnosis and Treatment
have been depleted
Ike - Echo
Treatment - Update
• Finish metronidazole, then start milk thistle
• Increase Kgluconate to 2 mEq PO BID
• Continue furosemide 5 mg PO BID
• Add enalapril 1.25 mg PO SID
– Recheck BUN/lytes 5 days
– If OK, increase to BID
– Recheck BUN/lytes 5 days
• Laxatone PRN for constipation
• Recheck echo, chest rads in 6 months or sooner if RR
> 40 at rest
• Ike died acutely just prior to his 6 month recheck
Pericardial Effusion
Clinical Features
• DDx
–
–
–
–
–
–
Pericarditis
Chronic CHF (usually RHF)
Blood – left atrial tear, HSA, coagulopathy
Pericardial cyst
Idiopathic
50% are neoplasia – carefully look at RA
• ECG – electrical alternans
Pericardial Effusion
Echocardiographic Abnormalities
• Careful not to confuse pericardial fat with
pericardial effusion
– Look at relative echogenicity
• Careful not to confuse normal anechoic
structures with pericardial effusion
– Descending aorta
– Enlarged left auricle
Pericardial Effusion
Echocardiographic Abnormalities
• Careful to distinguish pericardial from pleural
effusion
– Pericardium not visualized with pleural effusion
– Collapsed lung lobes may be seen with pleural
effusion (look like liver in US)
– Careful not to confuse consolidated lung with liver in
a peritineopericardial diaphragmatic hernia
• Heart may swing back & forth in the
pericardium
Pericardial Effusion
Echocardiographic Abnormalities
• Cardiac tamponade
–
–
–
–
–
Compression of RV
Diastolic collapse of RV
IVS may be flattened with paradoxical motion
Pericardiocentesis is imperative
Aggressive diuresis will reduce preload
• Evaluation of heart base tumor prior to
pericardiocentesis will be more thorough
Pericardial Effusion
Video Pericardial Effusion
Video Pleural Effusion
Video Consolidated Lung Lobe
Video Normal thorax
Video Mediastinal Mass
Taz
Signalment
• 7 year old neutered male sharpei
• Annual vaccines 2 weeks ago
Chief Complaint
• Hasn’t felt good since vaccines
• Breathing really hard
• Belly is swelling
• Not eating
Taz
Exam – RR 77, mm pale, CRT 4 sec
• Positive hepatojugular reflux
• Ascites
• Peripheral edema – ventral legs and ventral abdomen
• Muffled heart sounds
CBC, panel, lytes, heartworm test
• No abnormalities noted
Taz
Taz
Taz
Echocardiogram
• Pronounced pericardial effusion with cardiac
tamponade
• Pericardiocentesis – 1 L fluid that resembles blood
– Does not clot after 20 minutes
– PCV 38%, cytology non-septic exudate (hypersegmented
neutrophils)
• IV fluid bolus 500 ml
• Echo measurements after tap normal
PT, PTT, ACT
• normal
Taz
Abdominal US
• Normal
Sent pericardial fluid for culture and sensitivity
Emergency Referral to TAMU for Echocardiogram
• Taz was VERY painful on the ride to Bryan
• Small amount of pericardial effusion – not enough to tap
• No cardiac masses detected
• Abdominal ultrasound NSAF
• Discharged with no medications, to recheck in one week
Taz
Recheck 1 week
• Taz doing exceptionally well
• No growth on culture and sensitivity
• Signs of right heart failure have resolved
• No ascites, dyspnea, peripheral edema, jugular distension
• Abdominal palpation normal
•
•
•
•
•
Chest x-rays show VHS 11
Echo shows 2 cm pericardial effusion
Tapped again and dispensed pain meds
Rx doxycycline 10 mg/kg PO BID x 3 weeks
Rx prednisone 0.5 mg/kg PO SID x 2 weeks, then QOD
Taz
Recheck 30 days
• Exam, chest rads and echo are normal
• Taper off prednisone over the next 30 days
• Taz has had no recurrence of pericardial effusion in the
past 6 years
Cardiac Masses
DDx
• Chemodectoma
• HSA
• Myxosarcoma
• Ectopic thyroid carcinoma
• Mesothelioma
• LSA
• fibrosarcoma
Cardiac Masses
Echocardiographic Features
• Usually at the heart base or in the RA
• Careful not to confuse with
– Epicardial fat (especially on the AV groove when
there is pericardial effusion)
– Trabeculae on the right auricle when floating in
pericardial effusion
Hank
Signalment
• 10 week old male schnauzer
Chief Complaint
• Loud heart murmur heard on examination for routine
vaccinations
• Suspect congenital heart defect
Hank
Exam
• mm pink, CRT 2 sec
• 4/6 ejection murmur loudest at left heart base
• Mild superficial pyoderma
Hank
Initial Differential Diagnoses
• Pulmonic stenosis
• Aortic Stenosis
Initial Diagnostic Plan
• Chest x-rays
• EKG
• Echocardiogram
Hank
Hank
Hank
Thoracic radiographs
• Dorsally elevated trachea
• Vertebral heart score 9.5
• Right heart enlargement
• Right auricular/atrial enlargement
• Distended caudal vena cava
• Bulge at main pulmonary artery
Hank
EKG
• Tall P waves (0.5-0.6 mV)
• RA enlargement
• Deep S waves in leads I, II and III (-13 to -15 mV)
• RV enlargement
• Tachycardia 200-210 bpm
• Under Buprenex-ace sedation
Hank - Echo
Hank - Echo
Short Axis – LV Apex
• RV seems thickened
Short Axis – LV PM, MV, Ao/RVOT
• RV as thick as LV – markedly thickened
• IVS is flattened
Hank - Echo
Hank - Echo
Short Axis – PA
• MPA dilated
• RV as thick as LV – markedly thickened
Long Axis – 4 Chamber
• Aberrant septum dividing RA into 2 chambers – cranial
and caudal
Long Axis – LVOT
• RV as thick as LV – markedly thickened
Hank - Echo
Hank - Echo
Diagnosis
• Likely Pulmonic Stenosis
• DDx RV thickening
– Heartworms impossible in a 10 week old puppy
– Pulmonary hypertension rare in a 10 week old puppy
• Need Doppler to confirm, and to determine gradient
• Cor triatriatum dexter
Hank - Echo
Plan – updated
• Referral to TAMU for balloon valvuloplasty
• Atenolol 0.5 mg/kg PO BID (monitor weight to
increased dose PRN until cath procedure)
Pulmonic Stenosis
Clinical features
• Many breed predispositions
– Bulldog, chihuahua, Beagle, Cavalier
• Often valvular and subvalvular
• Valvular defect can be corrected by valvuloplasty
• Prognosis varies, depending on severity
– Mild – less than 50 mm Hg gradient
– Moderate – 50-100 mm Hg
– Severe - >100 mm Hg
• Can be progressive
Pulmonic Stenosis
Clinical features
• Bulldogs and Boxers can have left coronary artery
anomaly, which can preclude balloon valvuloplasty
• Arrhythmia is much more common than RHF
• May be part of Tetralogy of Fallot
–
–
–
–
PS
RV hypertrophy
VSD
Overriding aorta
Pulmonic Stenosis
Coronary Artery Anomaly
• Instead of R and L coronary
aa, there is a single
coronary a.
• It splits and the left branch
encircles the pulmonary a.
• It can be ruptured if the PS
is ballooned
• These dogs may have
normal PV and functional
PS due to this anomaly
Pulmonic Stenosis
Echocardiographic abnormalities
• RV thickening
• Post-stenotic dilatation of MPA
• Pulmonic valve may be thickened with poor movement
• Paradoxical septal motion may be noted in severe cases
• Tricuspid dysplasia is a common concurrent malformation
– RHF is rare in dogs with PS alone
– Many PS dogs that develop RHF also have tricuspid dysplasia
(Client Handout)