Hello,
This is a Bichon-Shitzu 11 years old M/N with episodes of weaknes, drooling, minor seizures. His bloodwork was unremarkable.
His RDVM recommended and AUS. One segment of ileum was abnormal with thick walls and reactive fat surrounding it. No obvious reason for his clinical symptoms.
Due to seizure/syncopae history and able to hear a systolic murmur I did “put “the probe on the heart to do the “eyeball quick exam”. I was able to see the mitral regurg jet but also an AO insuf. jet.
Hello,
This is a Bichon-Shitzu 11 years old M/N with episodes of weaknes, drooling, minor seizures. His bloodwork was unremarkable.
His RDVM recommended and AUS. One segment of ileum was abnormal with thick walls and reactive fat surrounding it. No obvious reason for his clinical symptoms.
Due to seizure/syncopae history and able to hear a systolic murmur I did “put “the probe on the heart to do the “eyeball quick exam”. I was able to see the mitral regurg jet but also an AO insuf. jet.
Was wondering if this is significant, if this dog can have volume pressure overload, decrease fractional shortening ( I’ve got 25%) with depressed contractility and if this can explain his syncopae episodes. If yes I will recommend a full ECho.
Thank you.
Comments
I am not a cardiologist- but
I am not a cardiologist- but I will give you my 2 cents. The normal response with a typical mitral regurg in a small breed dog would be volume overload of the L ventricle with a dilated L atrium. FS should be elevated until the myocardium decompensates late. I would guess that we should see signs of CHF.
To me this dog does not have a volume overload and the L atrium does not look all that dilated. In the second cine the ventricular walls look thickened and I wonder if this is especially true of the IVS. Maybe some is due to positioning.
Could we be dealing with some sort of cardiomyopathy or DLVOTO?
I would suggest a full echo and consider EKG/Holter monitoring.
We can now wait to see what EL and Peter have to say
Intersting case and now that
Intersting case and now that jet lag and planes trains autos are in my recent past this got me thinking…:
So this aortic insufficiency you can see with this red flare… (BART blue away red torward the transducer) in your last video… You would use duplex doppler with pw (example last image attached) then cw (images 2 and 3 attached) if needed over the red flare to identify the regurg jet in spectral with pw then quantify it with cw if it aliases > 2.5 m/sec or the usual limits of pw.
Subjectively Im guessing this is a low grade jet because the flare on your case in last video is just kinda there… if that makes sense …like leaving the faucet on just a touch on the garden hose where the water just kinda leaks out… whereas a solid AI jet (see my example images 2 and 3 duplex doppler attached here) with higher velocity the flare is straighter and just bounding to get back into the LV which suggests a higher pressure backflow subjectively. Also there is no significant LV hypertrophy in your case that would indicate that the heart is trying to compensate for a significant back pressure form the AI. Many dogs have a little AI and PI and are incidental but you would have to apply CW to assess any significant gradient here. Any time you have AI though you always have to keep endocarditis in mind… bartonella and other bugs (strep, e coli and such) can do this and camp out low grade especially in garden states like NJ where “anything grows” and may be AB responsive…. My shot gun on these if suspecting low grade endocarditis is Baytril/Clindamycin…or Doxy/Clindamycin and of course get a BP because I have seen AI in hypertensive cases as well which makes sense given the increased afterload. Hope this meat and potatoes explanation helps… Im sure Peter can be more technical on this.
Regarding the aabdominal portion of your case since I read the abdomen in our telemed service and the ileum lesion (image attached) supports spontaneous necrosis/early peritonitis without fluid yet… or emerging intestinal LSA or similar and regional ln enlargement shows that the pathology has at least entered local lymphatics (image attached)…so taking it one step further… lymphatics dump into the right atrium from the thoracic duct and into general curculation at least to some minor extent … what gets by the immune system and phgocytosis/complement and such… and why can’t some rogue e-coli localize at the AV given that its a high pressure gateway… all blood products bang the door here…. we would have to think potential early sepsis (check wbc and glucose levels in later stages) and bacterial leakage into the blooadstream in this case that may be in the cns as well or even metastatic neoplasia entering the cns and causing seizures… maybe there is a bacterial toxin in play here too… the cns sdoesnt lioke those:)… this may be an extreme and looking into the case too far but makes for nice banter and I like to look at the whole patient and consider the potentials and at least cover for them if the treatment can’t hurt…The heart is an effector organ and we see manifestations of that during the echo often… hypertension, shock, hypothyroidsim, pseudohypertrophy from volume contraction, flow murmur in a triad cat or newly hypertensive one… maybe even a new or higher grade MR with a newly hypertensive dog (now that’s a study to be designed)…just EL observations from the fringe of whole body sonography here… so when I see a heart I think “effector organ” first then cardio pathology second.
We like to put all the pieces together but often there is more than one puzzle involved. Maybe this soft flare AI has nothing to do with anything here but what if it is related to a leaky rogue bug from that pathological ileum and LN?… its a microspcopic issue that we can’t see…Blood cultures are poorly sensitive but may be more effective if plating in house and would be a good idea..but negative doesnt mean true negative either…if this is my dog im giving baytril clinda or baytril metronidazole to cover the spectrum and penetrate the cns and that ileum and rescanning in 3-5 days and see what happens or cutting out that ileum guided by intraoperative ultrasound (see interventional procedures in http://www.sonopath.com/resources/instructional-library-sonopodcasts-interventional-procedures) to ensure I got it all and treating the same as described above medically.
FYI along these instructional lines….Finished the next sonopath structural investment and development: We have enhanced our sonopod cast library (virtual instruction so you don’t have to sit through a lecture at some sunny destination where we hold our seminars:) and is now a significant part of the sonopath infrastructure for members… essentially you could spend a really nerdy week 24/7 going through these anonymized video recordings of my interpretation & technique recommendations of some telemed sonograms. If you wish to have a sonopod cast performed on your telemed case just upload your case normally for telemed read (http://www.sonopath.com/spa) and indicate sonopod cast in the drop down and we will send you a link to your video and anonymize it and adding it to our member library. Only at sonopath do we come up with these wacky nerdy tools:)
Our sonopod cast library is in resources tab:
http://www.sonopath.com/resources/instructional-library-sonopodcasts-interventional-procedures
Hi!
Thanks for your input,
Hi!
Thanks for your input, Eric!
I agree, this is very mild and insignificant AI. It’s most likely caused by some valvular degeneration since this dog has MMVD as well. Other causes would be aortic stenosis, VSD, endocarditis, severe systemic hypertension or some isolated mild dysplasia/degeneration of unkown origin. The assessment of severity is mostly based on color Doppler. Any aortic regurgitation that does not meet the level of the opened mitral valve tips is usually mild. A severe one goes down to the apex. You can also measure aortic regurg pressure half time on spectral Doppler but this is in my hands not superior to color alone.
The mild concentric hypertrophy seen here could be due to systemic hypertension, aortic stenosis or pseudo-hypertrophy due to dehydration. If the vmax across the LVOT is normal (<1.8 m/s), there is no aortic stenosis present. Systolic function is normal (forget FS…!)
So – I do not think that the syptoms are related to heart disease, unless there is no significant arrhythmia detected.
My suggestions for further work-up:
Full echo (incl. LVOT assessment)
abdominal scan
blood pressure (r/o pheochromocytoma)
ECG
blood workup
I hope I could help. If you have further questions, pls just post 🙂
Peter
Started this dog on baytril
Started this dog on baytril and metronidazole and apparently it is improving. Hist temp was 39.7 now normal. Wondering if this is endocarditis. Thsnk you all for your help:)