Practical Cardiology Case Studies Wendy Blount, DVM Nacogdoches TX Wendy Blount, DVM Nacogdoches TX.

Practical Cardiology Case Studies Wendy Blount, DVM Nacogdoches TX 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)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 pO 2 – 52 mmHg pCO 2 – 36 mmHg all else normal Pulse oximetry Lip – O 2 sat 89% Vulva - O 2 sat 67%

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 90 o Arrhythmia doesn’t seem likely Differential Diagnoses Right to left shunt Pulmonary hypertension

Ginger

ECG S wave mildly deep in leads II, III, aVF MEA 90 o 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) 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)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 Heart rate –P rate is 160 bpm, QRS rate is 100 bpm Rhythm –no consistent PR interval –P and QRS complexes are disassociated, but each regular 25 mm/sec 3 rd Degree AV block 20mm = 1 mV

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

3 rd degree AV block 3 rd Degree AV block is the most common cause of bradycardia in the cat Treatment- cats Often no treatment needed for cats –A–AV node pacemaker is 100 per minute –A–AV node pacemaker is 40-60 per minute in the dog Cats do well unless they undergo anesthesia Avoid drugs that increase vagal tone –A–Alpha blockers – Dexdomitor, Rompun

3 rd 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 2 nd degree block go away –Some have tried theophylline Prognosis poor without pacemaker If lactate is high, emergency pacemaker is needed

3 rd degree AV block in Dogs 50 mm/sec Pre-Operative ECG Atrial rate = 200 per minute Ventricular rate = 40 per minute

3 rd 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 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 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 – 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

Long Axis – LVOT(video)video Hyperechoic thickened mitral valve leaflets Diagnosis Aortic endocarditis Therapeutic Plan Elected euthanasia due to poor prognosis

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 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)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 –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

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 IVSTD – 10.2 (n 3-6) LVIDD – 14.1 (n 10-21) LVPWD – 6.95 (n 3-6) IVSTS – 14.85 (4-9) LVIDS – 3.5 (n 4-10) LVPWS – 9.6 (n 4-11) FS – (14.1-3.5)/14.1 = 74.5% EF = 98% Dx – Hypertrophic Cardiomyopathy

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

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

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 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 VideoVideo Pericardial Effusion VideoVideo Pleural Effusion VideoVideo Consolidated Lung Lobe VideoVideo Normal thorax VideoVideo 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

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

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

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

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

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)Client Handout

Practical Cardiology Case Studies Wendy Blount, DVM Nacogdoches TX Wendy Blount, DVM Nacogdoches TX.

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Practical Cardiology Case Studies Wendy Blount, DVM Nacogdoches TX Wendy Blount, DVM Nacogdoches TX.

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