1 / 68

Basic Echocardiography Case Studies

Basic Echocardiography Case Studies. Wendy Blount, DVM Nacogdoches TX. Jake. Signalment 9 year old male Boxer Chief Complaint Deep cough when walking in the morning, for about one week Appetite is good. Jake. Exam Weight 81.9 – has lost 5 pounds in 3 months (BCS 3) Temp 101.4

andren
Télécharger la présentation

Basic Echocardiography Case Studies

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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 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) FS = LVIDD – LVIDS LVIDD (72.1-67.1)/72.1 = 7% (n 30-46%) EF = 15% (n >70%)

  10. Jake - Echo Transverse - Mitral Valve • No increased thickness of MV • No vegetations on the MV • EPSS – 12 mm (n <6 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) • LA:Ao = 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 >40 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 < 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 • Daisy’s 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 don’t 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

More Related