Basic Echocardiography Case Studies

1
Basic EchocardiographyCase Studies

• Wendy Blount, DVM
• Nacogdoches TX

2
Jake

• Signalment
• 9 year old male Boxer
• Chief Complaint
• Deep cough when walking in the morning, for about
  one week
• Appetite is good

3
Jake

• Exam
• Weight 81.9 has lost 5 pounds in 3 months (BCS
  3)
• Temp 101.4
• Mucous membranes pink, CRT 3.5 seconds
• Subtle dependent edema on the lower legs
• Jugular veins normal
• Harsh lung sounds
• 3/6 holosystolic murmur, PMI left apex
• Heart rate 160 per minute
• Respirations 55 per minute
• Femoral pulses somewhat weak

4
Jake

• Differential Diagnosis - Cough
• Respiratory Disease
• Cardiovascular Disease
• Both

5
Jake

• Diagnostic Plan (B Client)
• Blood Pressure
• 150 mm Hg systolic (Doppler)
• Chest X-rays
• Massively enlarged heart (VHS 12.5)
• Enlarged LA, LV (dorsally elevated trachea)
• Enlarged pulmonary veins
• Perihilar pulmonary edema
• Left congestive heart failure

6
Jake

• Immediate Therapeutic Plan (10 am)
• Furosemide
• 80 mg IM
• 4 hours later
• Respiratory rate is 36 per minute

7
Jake

• Diagnostic Plan 2nd Wave (2 pm)
• EKG
• Normal Sinus Rhythm
• Echocardiogram

8
Jake - Echo

• Transverse - LV Apex
• LV Looks Big
• Transverse - LV Papillary Muscles
• LV looks REALLY big
• Myocardium is hardly moving
• Flat papillary muscles

9
Jake - Echo
FS LVIDD LVIDS
LVIDD (72.1-67.1)/72.1 7 (n 30-46) EF 15
(n gt70)

• Transverse - LV Papillary Muscles
• IVSTD 9.7 mm (n 10.8-12.3)
• LVIDD 72.1 mm (n 43-48)
• LVPWD 15.1 mm (n 8.7-10)
• IVSTS 11.9 mm (n 16.5-18.1)
• LVIDS 67.1 mm (n 27.4-30.4)
• LVPWS 13.0 mm (n 14-15.6)

10
Jake - Echo

• Transverse - Mitral Valve
• No increased thickness of MV
• No vegetations on the MV
• EPSS 12 mm (n lt6 mm)
• Transverse Aortic Valve/RVOT
• LA at least Double Big

11
Jake - Echo

• Transverse - Aortic Valve/RVOT
• AoS 23.1 mm (n 27.4-30.4)
• LAD 44.7 mm (n 25.8-28.4)
• LAAo 44.7/23.1 1.9 (n 0.8-1.3)
• Transverse Pulmonary Artery
• No abnormalities noted

12
Jake - Echo

• Long 4 Chamber
• LV massively enlarged
• Poor systolic function
• LA 2x enlarged
• IVS is bowed toward the right, due to LV dilation
• Long LVOT
• No abnormalities in LVOT

13
Jake Dx Tx

• Recommendations
• Left Congestive Heart Failure
• Mini-panel and electroytes
• Furosemide 80 mg PO BID
• Enalapril 20 mg PO BID
• Recheck mini-panel and electrolytes in 3-5 days
• Recheck chest rads 3-5 days
• Dilated Cardiomyopathy
• Pimobendan 10 mg PO BID (declined)
• Carnitine 2 g PO BID
• Recheck echo, chest rads, EKG, mini-panel/lytes
  60 days (sooner if respiratory rate gt40 at rest)

14
Jake - Bloodwork

• CBC
• normal
• Mini-panel - BUN, creat, glucose, TP, SAP, ALT
• Normal
• Electrolytes
• Not done

15
Jake Follow-Up

• Recheck 6 days
• BUN 30 (n 10-29)
• Creat normal
• Electrolytes not done
• Chest x-rays not done
• 60 day Recheck - Pending

16
Dilated Cardiomyopathy

• Common Echocardiographic Lesions
• Dilation of all 4 heart chambers
• Large LVIDD (eventually large LVIDS also)
• Hypokinesis of LV wall and IVS
• Reduced FS
• Paradoxical septal motion
• Increased EPSS
• Normal looking MV and TV leaflets
• Papillary muscle flattening

17
Dilated Cardiomyopathy

• Video

18
Pocket

• Signalment
• 13 year old spayed female yorkie (5 pounds)
• Chief Complaint
• Harsh cough several times daily for 2 months
• History of chronic inflammatory liver disease,
  luxating patellas, chronic periodontal disease
  and multiple allergies these problems
  clinically doing well at this time.
• Mammary carcinoma removed one year previously, at
  the time of OHE.

19
Pocket

• Exam
• Temp 100.3, P 110, R 26, BP 110, BCS 3.5
• BAR, well hydrated, in good body condition
• Crackles in the small airways, especially at peak
  inspiration
• Pronounced respiratory sinus arrhythmia
• Normal heart sounds
• Pulses normal, CRT lt 2 sec
• Mature cataract right eye

20
Pocket

• Differential Diagnoses - Cough
• Chronic Bronchitis
• Collapsing trachea
• Diagnostic Plan - initial
• Chest and cervical x-rays
• Inspiratory - VD and right lateral
• Expiratory - left lateral

21
Pocket

• Thoracic and cervical radiographs
• No collapse of the trachea
• Vertebral heart score 10
• Normal cardiac silhouette and pulmonary
  vasculature
• Pronounced peribronchiolar pattern
• Shoulder arthritis
• Vertebral arthritis
• Normal sized liver

22
Pocket

• Diagnostics 2nd round
• Transtracheal wash
• Cytology suppurative inflammation (mature
  neutrophils)
• Culture negative
• Treatment Diagnosis Chronic Bronchitis
• Hydrocodone as needed for cough suppression
• Inhaled steroids PRN for cough

23
Daisy

• Signalment
• 15 year old spayed female mixed terrier
• 11 pounds
• Chief Complaint
• Became dyspneic while on vacation, as they drove
  over a mountain pass
• Come to think of it, she has been breathing hard
  at night for some time

24
Daisy

• Exam
• T 100.2, P 185, R 66, BP 145, BCS 3.5
• Increased respiratory effort
• 3/6 holosystolic murmur loudest at left apex
• Mucous membranes pale pink
• Crackles in the small airways
• Pulses weak
• CRT 3.5-4 seconds

25
Daisy

• Differential Diagnosis - Dyspnea
• Suspect congestive heart failure
• Suspect mitral regurgitation
• Concurrent respiratory disease can not be ruled
  out
• Initial Diagnostic Plan
• Chest x-rays
• CBC, mini-panel, electrolytes

26
Daisy

• CBC, mini-panel, electrolytes
• Normal
• Thoracic radiographs
• Markedly enlarged LA
• Compressed left mainstem bronchus
• Perihilar edema
• Vertebral heart score 11.75
• Elevated trachea LV enlargement
• Right heart enlargement

27
Daisy

• Initial Therapeutic Plan
• Lasix 25 mg IM, then 12.5 mg PO BID
• Enalapril 2.5 mg PO BID
• Owner is a lab tech, and set up oxygen mask to
  use PRN at home
• Recheck BUN, potassium, chest rads 3-5 days
• Come back sooner if respiratory rate at rest is
  above 40 per minute without oxygen

28
Daisy

• Recheck 4 days
• Daisys breathing is much improved (30-40 at
  rest)
• Lateral chest x-ray
• Electrolytes normal
• BUN 52

29
Daisy

• Diagnostic Plan - updated
• Decrease enalapril to SID
• Recheck BUN 1 week
• Recheck chest rads 1 week
• Recheck 1 week
• BUN 37
• Thoracic rads no change
• Request recheck in 3 months, or sooner if
  respiratory rate at rest is above 40 per minute

30
Daisy

• 2 months later
• Daisy is breathing hard again at night
• Exam
• Same as initial presentation
• Diagnostic Plan
• CBC, mini-panel, electrolytes
• Chest x-rays

31
Daisy

• Bloodwork
• CBC, electrolytes normal
• BUN 88
• Therapeutic Plan
• Increase furosemide to 18.75 mg PO BID
• Add hydralazine 2.5 mg PO BID
• Recheck chest rads, BUN, electrolytes, blood
  pressure 1 week

32
Daisy

• Recheck 1 week
• Clinically much improved respiratory rate 30-40
  per minute at rest
• electrolytes normal
• BUN 58
• Blood pressure 135
• Chest x-rays
• Recommend recheck in 3 months, or sooner if
  respiratory rate above 40 per minute at rest

33
Daisy

• Recheck 6 months
• Daisy dyspneic again
• Exam
• Similar to last crisis BP 90
• Diagnostic Plan
• CBC, mini-panel, electrolytes, chest x-rays
• Echocardiogram

34
Daisy

• Bloodwork
• CBC, electrolytes normal
• BUN 105, creat 2.1
• Chest x-rays
• Similar to last crisis

35
Daisy - Echo

• Short Axis LV apex
• LV looks big
• Short Axis LV papillary muscles
• IVSTD 6.0 mm low normal
• LVIDD 35 mm (n 20.2-25)
• LVPWD 4.3 mm low normal
• IVSTS 9.4 mm normal
• LVIDS 25 mm (n 11.1-14.6)
• LVPWS 8.4 mm - normal

36
Daisy - Echo

• Short Axis LV papillary muscles
• IVSTD 6.0 mm low normal
• LVIDD 35 mm (n 20.2-25)
• LVPWD 4.3 mm low normal
• IVSTS 9.4 mm normal
• LVIDS 25 mm (n 11.1-14.6)
• LVPWS 8.4 mm normal
• FS (35-25)/35 29 (normal 30-46)

37
Daisy - Echo

• Short Axis - MV
• MV leaflets hyperechoic and thickened
• EPSS 8 mm (n 0-6)
• Short Axis Aortic Valve/RVOT
• LA appears 2-3x normal size
• AoS 13.0 normal
• LAD 33 mm (n 12.8-15.6)
• LA/Ao 2.5 (n 0.8-1.3)

38
Daisy - Echo

• Long View 4 Chamber
• LV and LA both appear large
• MV is very thick and knobby, with some prolapse
  into the LA
• Long View LVOT
• Large LA, Large LV

39
Daisy - Echo

• Therapeutic Plan
• Increase hydralazine to 5 mg PO BID
• Add spironolactone 12.5 mg PO BID
• Add pimobendan 1.25 mg PO BID
• Increase furosemide to 18.75 mg PO TID x 2 days,
  then decrease to BID if respiratory rate
  decreases to less than 40 per minute at rest.
• Recheck 1 week BUN, creat, phos, electrolytes,
  chest rads, BP

40
Daisy - Echo

• Recheck 1 week
• Clinically improved again
• BP - 125
• BUN 132, creat 2.6, phos 6.6
• Electrolytes normal
• chest rads improved pulmonary edema
• Therapeutic Plan Update
• Add aluminum hydroxide gel 2 cc PO BID

41
Daisy - Echo

• 5 Months later
• Coughing getting worse
• Chest rad show no pulmonary edema
• LA getting larger
• Therapeutic Plan Update
• Add torbutrol 2.5 mg PO PRN to control cough

42
Daisy - Echo

• 18 Months after initial presentation
• Owner discontinue pimobendan due to GI upset
• 20 months after initial presentation
• Daisy is still alive.
• Furosemide 20 mg PO TID
• Hydralazine 5 mg PO BID
• Spironolactone 12.5 mg PO BID
• We dont want to know how high her BUN is

43
Chronic MV Disease

• May be accompanied by similar TV disease (80)
• TV disease without MV disease is possible but
  rare
• LHF and/or RHF can result
• Right heart enlargement can develop due to
  pulmonary hypertension due to LHF
• Myocardial failure and CHF are not directly
  related

44
Chronic MV Disease

• Echo abnormalities
• LA and/or RA dilation, LV and/or RV dilation
• Exaggerated IVS motion (toward RV in diastole)
• Increased FS first, then later decreased FS
• Thickened valve leaflets
• If TV only affected, left heart can appear
  compressed, small and perhaps artifactually thick
• Ruptured CT
• MV flips around in diastole
• MV flies up into LA during systole
• May see trailing CT, or CT floating in the LV

45
Chronic MV Disease

• Video

46
Jasper

• Signalment
• Middle Aged Adult Norwegian Forest Cat
• Male Castrated
• 13 pounds
• Chief Complaint
• Acute Dyspnea 1 day after sedation with ketamine
  and Rompun for grooming

47
Jasper

• Immediate Diagnostic Plan
• Lasix 25 mg IM give 1 hour in cage
• 1 lateral thoracic radiograph
• Differential Diagnosis Pleural effusion
• Transudate - Hypoalbuminemia
• Modified Transudate Neoplasia, CHF
• Exudate Blood, Pyothorax, FIP
• Chylothorax

48
Jasper

• Initial Therapeutic Plan
• Thoracocentesis
• Tapped both right and left thorax
• Removed 400 ml of pink opaque fluid that
  resembled pepto bismol
• Fluid had no chunks in it
• Differential Diagnosis updated
• Pyothorax
• Chylothorax

49
Jasper

• Initial Diagnostic Plan
• Fluid analysis
• Total solids 5.1
• SG 1.033
• Color- pink before spun, white after
• Clarity opaque
• Nucelated cells 8500/ml
• RBC 130,000/ml
• HCT 0.7

50
Jasper

• Initial Diagnostic Plan
• Fluid analysis
• Lymphocytes 5600/ml
• Monocytes 600/ml
• Granulocytes 2300/ml
• No bacteria seen
• Triglycerides 1596 mg/dl
• Cholesterol 59 mg/dl
• Chylothorax

51
Jasper

• DDx Chylothorax
• Trauma was chewed by a dog 2-3 mos ago
• Right Heart Failure
• Pericardial Disease
• Heartworm Disease
• Neoplasia
• Lymphoma
• Thymoma
• Idiopathic

52
Jasper

• Diagnostic Plan - Updated
• PE Cardiovascular exam
• CBC, general health profile, electrolytes
• Occult heartworm test
• Post-tap chest x-rays
• Echocardiogram

53
Jasper

• Exam
• Temp 100, P 180, R 48, BCS 3, BP 115
• 3/6 systolic murmur
• Anterior mediastinum compressible
• Pleural rubs
• No jugular pulses, no hepatojugular reflux
• Peripheral pulses slightly weak
• Mucous membranes pink, CRT 3 sec

54
Jasper

• Bloodwork
• Occult Heartworm Test - negative
• CBC normal
• GHP
• Glucose 134 (n 70-125)
• Cholesterol 193 TG 137 (both normal)
• Chest X-rays
• Post-tap chest x-rays

55
Jasper

• Chest X-rays
• Minimal pleural effusion
• No cranial mediastinal masses
• Normal cardiac silhouette (VHS 7.5)
• Normal pulmonary vasculature
• Lungs remain scalloped

56
Jasper Echo

• Short Axis LV apex
• No abnormalities noted
• Short Axis LV PM
• No abnormalities noted
• IVSTD 8.8 mm (n 3-6)
• LVIDD 16.2 mm (normal)
• LVPWD 7.2 mm (n 3-6)
• IVSTS 9.8 mm (n 4-9)
• LVIDS 10.5 mm (normal)
• FS 35

57
Jasper Echo

• Short Axis MV
• No abnormalities noted
• Short Axis Ao/RVOT
• Smoke in the LA
• AoS 11.7 mm ( normal)
• LAD 10.5 (normal)
• LA/Ao 0.9 (normal)

58
Jasper Echo

• Short Axis PA
• Difficult to evaluate due to rib shadows
• Long Axis 4 Chamber
• Hyperechoic thingy in the LA, with smoke
• Long Axis LVOT
• Aortic valve seems hyperechoic, but not nodular
• 2-3 cm thrombus free in the LA

59
Jasper Echo

• Short Axis Ao/RVOT
• LA 2-3x normal size, with Smoke
• AoS 11.7 mm ( normal)
• LAD 29 mm (n 7-17)
• LA/Ao 2.5 (n 0.8-1.3)

60
Jasper Echo

• Therapeutic Plan - Updated
• Furosemide 12.5 mg PO BID
• Enalapril 2.5 mg PO BID
• Rutin 250 mg PO BID
• Low fat diet
• Plavix 18.75 mg PO SID
• Lovenox 1 mg/kg BID
• Fragmin 1 mg/kg BID
• Clot busters only send the clot sailing

61
Jasper Echo

• Recheck 1 week
• Jasper doing expectionally well back to normal.
• Lateral chest radiograph
• Jasper declined all other diagnostics, without
  deep sedation/anesthesia
• Will do BUN, Electrolytes, BP, recheck echo to
  assess thrombus in one month

62
Jasper Echo

• Recheck 1 month
• Jasper doing expectionally well
• Lateral chest radiograph no change
• Jasper declined all other diagnostics, without
  deep sedation/anesthesia
• Will do BUN, Electrolytes, BP, recheck echo to
  assess thrombus at 6 month check-up.

63
Hypertrophic Cardiomyopathy

• Clinical Characteristics
• Diastolic dysfunction heart does not fill well
• Poor cardiac perfusion
• Most severe disease in young to middle aged males
• Atria sometimes look enlarged on rads
• Can present as
• Murmur on physical exam
• Heart failure (often advanced at first sign)
• Acute death
• Saddle thrombus

64
Hypertrophic Cardiomyopathy

• Echocardiographic Abnormalities
• LV and/or IVS thicker than 6 mm in diastole
• Symmetrical or asymmetrical
• Can be only a thick IVS
• Can be primarily very thick papillary muscles
• LVIDD usually normal to slightly reduced
• FS normal to increased, unless myocardial failure
  developing
• LVIDS sometimes 0 mm

65
Hypertrophic Cardiomyopathy

• Echocardiographic Abnormalities
• LA often enlarged
• RA sometimes also enlarged
• Smoke can be seen in the LA
• Rarely a thrombus in the LA
• Transesophageal US more sensitive at detecting LA
  thrombi
• Borderline thickened LV should not be diagnosed
  as HCM without LA enlargement

66
Hypertrophic Cardiomyopathy

• DDx LV thickening
• Hypertension
• Hyperthyroidism
• (Chronic renal failure)

67
Hypertrophic Cardiomyopathy

• Treatment HCM
• Manage heart failure
• Therapeutic thoracocentesis in a crisis
• Diuretics
• ACE inhibitors
• Beta blockers if persistent tachycardia
• Calcium channel blockers if thickening
  significant
• Treat hypertension if present

68
Hypertrophic Cardiomyopathy

• Video