- Aggressive 11 year old mn Shih Tzu with a Grade 2/6 systolic murmur and peri-anal tumors
- Echo shows MVI with slight left atrial enlargement and a trans 2D LA/AO=1.5
- Rest of measurements are as follows: LA=19.2, AO=12.9, LA/AO=1.5, MPA=10.4, Ao=10.6, MPA/AO=9.8, IVSd=6.6, LVIDd=32.4, LVPWd=7.2, IVSs=12.2, LVIDs=15.0, LVPWs=10.8, FS=54%, HR=174 bpm
- Dog weighs 6kg. He was quite fractious throughout the exam which probably explains the elevated HR
- He has no clinical signs of heart disease at home
- Aggressive 11 year old mn Shih Tzu with a Grade 2/6 systolic murmur and peri-anal tumors
- Echo shows MVI with slight left atrial enlargement and a trans 2D LA/AO=1.5
- Rest of measurements are as follows: LA=19.2, AO=12.9, LA/AO=1.5, MPA=10.4, Ao=10.6, MPA/AO=9.8, IVSd=6.6, LVIDd=32.4, LVPWd=7.2, IVSs=12.2, LVIDs=15.0, LVPWs=10.8, FS=54%, HR=174 bpm
- Dog weighs 6kg. He was quite fractious throughout the exam which probably explains the elevated HR
- He has no clinical signs of heart disease at home
Since his myocardial function is hyperdynamic and his LA enlargement is mild, would it be an ok plan to start him on enalapril and go forward with anesthesia provided that caution is used with IV fluid administration and anesthetic drug selection? I am also recommending chest radiographs to rule out any CHF and to use as a baseline for VHS. Blood pressure measurements in the hospital are not going to be feasible as he will probably not hold still and because he gets so worked up. Because he is so aggressive, he will probably need sedation prior to propofol induction/isoflurane maintentance. Any other thoughts? I hate writing a blank check for anesthesia but looking at risk vs. benefit, it is probably a good idea to get the perianal tumors removed and submitted for histopath.
Comments
Any chance you can show a
Any chance you can show a couple of mmodes and a 4-5 chamber rt ps long axis video tp go woth the measurments?
Any chance you can show a
Any chance you can show a couple of mmodes and a 4-5 chamber rt ps long axis video tp go woth the measurments?
Yes, I have added them to the
Yes, I have added them to the orginal post.
Yes, I have added them to the
Yes, I have added them to the orginal post.
Debatable on these B
Debatable on these B stage VD cases. Maybe he is hypertesnive to justify an Ace-i? No true evidence shows that ace-i help in these cases.
Re anesthesia: torb premed, propofol, iso is my routine.
Here is a summary on the acvim consensus on valve disease:
A consensus panel comprised of many respected cardiologists have presented at ACVIM several times and eventually published specific recommendations with regard to the therapy for acquired valve disease in dogs. The summary of their recommendations was published in the Journal Veterinary Internal Medicine 2009;23:1142-1150 (C. Atkins, J. Bonagura, S. Ettinger, P. Fox, S. Gordon , J. Haggstrom, R. Hamlin, B. Keene, V. Luis-Fuentes and R. Stepien).
Prior to making specific recommendations, the panel revealed a novel stratification system to classify cardiac disease in dogs (as opposed to the NYHA Classification system).
1) Stage A: high risk of cardiac disease – no morphological changes or clinical signs (example a young Cavalier King Charles Spaniel, Cocker Spaniel or poodle).
2) Stage B1 – murmur; no chamber enlargement
3) Stage B2 – murmur with left atrial and left ventricular enlargement but asymptomatic
4) Stage C – past or current clinical signs of heart failure
n Acute
n Chronic
5) Stage D – end stage disease refractory to standard therapy of diuretics, ACEI and pimobendan
The following recommendations will be divided into those with full consensus, which required unanimous agreement between the panelists. Those recommendations that did not fill that criteria (unanimous agreement) were presented as non-consensus.
Stage A (high risk of cardiac disease – no clinical signs; no murmur yet
Consensus:
n No medical therapy
n No dietary therapy
n Yearly auscultation by vet
n Breeding dogs:
n +/- screening at breed sponsored events
n Do not breed if MR is identified during breeding age (<6-8 yrs)
Stage B1 (murmur; no chamber enlargement) – Diagnostics
Consensus:
n Radiographs – assessment and baseline
n BP
n Large breed: echocardiography (may have DCM on not evident radiographically)
n Small breed: +/- echocardiography
n Labs: HCT, TP, CR and U/A
Stage B1 (murmur; no chamber enlargement) – Treatment
Consensus:
n No medical therapy
n No dietary therapy
n Recheck radiographs and echocardiogram in one year
n (earlier- in large breed dog which may progress faster)
Stage B2 (murmur and LAE/LVE)
No Consensus Achieved ** Controversial – this is the most controversial part of the discussion
n ACEI: enalapril at 0.5 mg/kg SID/BID or benazepril 0.25-0.5 mg/kg SID
n Majority use for clinically relevant LAE or progressive disease
n Minority – no medical therapy
n Studies indicate either no effect on onset of CHF or small positive effect
n Beta-blockers
n Mild sodium restriction
n Majority
n Other medications
n Pimobendan, digoxin, spironolactone, amlodipine ???? (used by some panelists in specific situations)
n Large breed dogs
n Advocates of ACEI / beta blockers promote their use in stage B2.
Stage C Acute CHF – Diagnostics
Consensus:
n Differentiate cardiogenic vs. primary respiratory
n Thoracic radiographs
n Echocardiography
n Lab work
n Signalment, physical exam
n NT-proBNP?? No consensus yet (consensus made prior to much of the information on this diagnostic test)
Stage C -In hospital Treatment
Consensus:
n Lasix 2 mg/kg IV/IM hourly until the RR decreases OR total dose 8 mg/kg total dose OR constant rate infusion 1 mg/kg/hr for life threatening pulmonary edema.
n Pimobendan 0.25-0.3 mg/kg PO BID (acute phase as well as chronic therapy)
n Oxygen
n Abdominocentesis/ thoracocentesis
n Nursing care
n Sedation (anti-anxiolytic)
n Butorphanol (0.2-0.25 mg/kg IM/IV)
n Buprenorphine/ acepromazine
n Morphine, hydrocodone
n Sodium nitroprusside CRI (used in referral centers with advanced training and monitoring only)
No Consensus (Stage C- continued) :
n ACEI – used by majority of panelists in acute severe cases
n enalapril 0.5 mg /kg PO BID
n Nitroglycerin ½” per 10kg for 24-36 hr (+/- 12 hr on or off)
Stage C – At Home Therapy
Consensus:
n Lasix 2 mg/kg PO BID
n increase incrementally PRN(range 1-2 mg/kg BID to 4-6 mg/kg PO TID)
n ACEI enalapril 0.5 mg /kg PO BID
n Pimobendan 0.25-0.3 mg/kg PO BID
n Do not start beta blocker in face of CHF
n At home monitoring
n weight, RR, HR, appetite
Stage D – In Hospital Therapy
Consensus: No Consensus:
n Lasix CRI 1 mg/kg/hr Pimobendan TID dose off label
n Enalapril/ benazepril Sodium nitroprusside/ dobutamine CRI
n Pimobendan Sildenafil 1-2 mg/kg PO BID (minority)
n Centesis even without PH
n Oxygen or mechanical ventilation Bronchodilators (minority)
n Afterload reduction:
n Sodium nitroprusside
n Hydralazine
n Amlodipine
Stage D – At Home Therapy
Consensus:
n Lasix – adjust frequency or route (SC)
n Spironolactone
n Beta blockers – contraindicated
No Consensus:
n Hydrochlorthiazide –as an additional diuretic – monitor BUN/Cr and electrolytes
n Pimobendan TID
n Digoxin (as for stage C) +/- atrial fibrillation
n Sildenafil (1-2 mg/kg PO BID) for pulmonary hypertension
n Beta blockers – do not discontinue if stable but reduce if bradycardic or hypotensive
n Cough suppressants
n Bronchodilators
n Decrease sodium intake if possible
References:
Journal Veterinary Internal Medicine 2009;23:1142-1150 (C. Atkins, J. Bonagura, S. Ettinger, P. Fox, S. Gordon , J. Haggstrom, R. Hamlin, B. Keene, V. Luis-Fuentes and R. Stepien).
Debatable on these B
Debatable on these B stage VD cases. Maybe he is hypertesnive to justify an Ace-i? No true evidence shows that ace-i help in these cases.
Re anesthesia: torb premed, propofol, iso is my routine.
Here is a summary on the acvim consensus on valve disease:
A consensus panel comprised of many respected cardiologists have presented at ACVIM several times and eventually published specific recommendations with regard to the therapy for acquired valve disease in dogs. The summary of their recommendations was published in the Journal Veterinary Internal Medicine 2009;23:1142-1150 (C. Atkins, J. Bonagura, S. Ettinger, P. Fox, S. Gordon , J. Haggstrom, R. Hamlin, B. Keene, V. Luis-Fuentes and R. Stepien).
Prior to making specific recommendations, the panel revealed a novel stratification system to classify cardiac disease in dogs (as opposed to the NYHA Classification system).
1) Stage A: high risk of cardiac disease – no morphological changes or clinical signs (example a young Cavalier King Charles Spaniel, Cocker Spaniel or poodle).
2) Stage B1 – murmur; no chamber enlargement
3) Stage B2 – murmur with left atrial and left ventricular enlargement but asymptomatic
4) Stage C – past or current clinical signs of heart failure
n Acute
n Chronic
5) Stage D – end stage disease refractory to standard therapy of diuretics, ACEI and pimobendan
The following recommendations will be divided into those with full consensus, which required unanimous agreement between the panelists. Those recommendations that did not fill that criteria (unanimous agreement) were presented as non-consensus.
Stage A (high risk of cardiac disease – no clinical signs; no murmur yet
Consensus:
n No medical therapy
n No dietary therapy
n Yearly auscultation by vet
n Breeding dogs:
n +/- screening at breed sponsored events
n Do not breed if MR is identified during breeding age (<6-8 yrs)
Stage B1 (murmur; no chamber enlargement) – Diagnostics
Consensus:
n Radiographs – assessment and baseline
n BP
n Large breed: echocardiography (may have DCM on not evident radiographically)
n Small breed: +/- echocardiography
n Labs: HCT, TP, CR and U/A
Stage B1 (murmur; no chamber enlargement) – Treatment
Consensus:
n No medical therapy
n No dietary therapy
n Recheck radiographs and echocardiogram in one year
n (earlier- in large breed dog which may progress faster)
Stage B2 (murmur and LAE/LVE)
No Consensus Achieved ** Controversial – this is the most controversial part of the discussion
n ACEI: enalapril at 0.5 mg/kg SID/BID or benazepril 0.25-0.5 mg/kg SID
n Majority use for clinically relevant LAE or progressive disease
n Minority – no medical therapy
n Studies indicate either no effect on onset of CHF or small positive effect
n Beta-blockers
n Mild sodium restriction
n Majority
n Other medications
n Pimobendan, digoxin, spironolactone, amlodipine ???? (used by some panelists in specific situations)
n Large breed dogs
n Advocates of ACEI / beta blockers promote their use in stage B2.
Stage C Acute CHF – Diagnostics
Consensus:
n Differentiate cardiogenic vs. primary respiratory
n Thoracic radiographs
n Echocardiography
n Lab work
n Signalment, physical exam
n NT-proBNP?? No consensus yet (consensus made prior to much of the information on this diagnostic test)
Stage C -In hospital Treatment
Consensus:
n Lasix 2 mg/kg IV/IM hourly until the RR decreases OR total dose 8 mg/kg total dose OR constant rate infusion 1 mg/kg/hr for life threatening pulmonary edema.
n Pimobendan 0.25-0.3 mg/kg PO BID (acute phase as well as chronic therapy)
n Oxygen
n Abdominocentesis/ thoracocentesis
n Nursing care
n Sedation (anti-anxiolytic)
n Butorphanol (0.2-0.25 mg/kg IM/IV)
n Buprenorphine/ acepromazine
n Morphine, hydrocodone
n Sodium nitroprusside CRI (used in referral centers with advanced training and monitoring only)
No Consensus (Stage C- continued) :
n ACEI – used by majority of panelists in acute severe cases
n enalapril 0.5 mg /kg PO BID
n Nitroglycerin ½” per 10kg for 24-36 hr (+/- 12 hr on or off)
Stage C – At Home Therapy
Consensus:
n Lasix 2 mg/kg PO BID
n increase incrementally PRN(range 1-2 mg/kg BID to 4-6 mg/kg PO TID)
n ACEI enalapril 0.5 mg /kg PO BID
n Pimobendan 0.25-0.3 mg/kg PO BID
n Do not start beta blocker in face of CHF
n At home monitoring
n weight, RR, HR, appetite
Stage D – In Hospital Therapy
Consensus: No Consensus:
n Lasix CRI 1 mg/kg/hr Pimobendan TID dose off label
n Enalapril/ benazepril Sodium nitroprusside/ dobutamine CRI
n Pimobendan Sildenafil 1-2 mg/kg PO BID (minority)
n Centesis even without PH
n Oxygen or mechanical ventilation Bronchodilators (minority)
n Afterload reduction:
n Sodium nitroprusside
n Hydralazine
n Amlodipine
Stage D – At Home Therapy
Consensus:
n Lasix – adjust frequency or route (SC)
n Spironolactone
n Beta blockers – contraindicated
No Consensus:
n Hydrochlorthiazide –as an additional diuretic – monitor BUN/Cr and electrolytes
n Pimobendan TID
n Digoxin (as for stage C) +/- atrial fibrillation
n Sildenafil (1-2 mg/kg PO BID) for pulmonary hypertension
n Beta blockers – do not discontinue if stable but reduce if bradycardic or hypotensive
n Cough suppressants
n Bronchodilators
n Decrease sodium intake if possible
References:
Journal Veterinary Internal Medicine 2009;23:1142-1150 (C. Atkins, J. Bonagura, S. Ettinger, P. Fox, S. Gordon , J. Haggstrom, R. Hamlin, B. Keene, V. Luis-Fuentes and R. Stepien).
Ok, thanks!
Ok, thanks!
Ok, thanks!
Ok, thanks!
Hi, Just wanted to add to
Hi, Just wanted to add to EL’s comments.
When I have a patient like this in my practice, I tell the client that the patient is at higher risk for general anesthesia and I will use cardiac friendly sedation and anesthesia to minimize stress on the heart. With a mildly enlarged LA and no MV prolapse, then I would expect a good outcome. But with Mitral valve disease (MVD) my worry is that a chord may break which leads to sudden decompensation and possibly death. Very sad and unpredictable. So, in addition to RRR and chest films, I look carefully for a flailed leaflet or mitral valve prolapse to help me determine risk and long term prognosis.
There are other indices that can be measured to help you evaluate the severity of disease. Serum NT-proBNP concentration and selected Doppler echocardiographic variables such as mitral inflow measurements and E:IVRT ratio are helpful. See Schober JAVMA, Vol 239, No. 4, August 15, 2011.
Regarding systemic hypertension: If you are able to measure MR in the left apical view with your 6S then you can indirectly measure the minimum systolic BP in this dog. Whatever maxMR pressure gradient that you calculate, then the systolic BP is at least that much. It could be higher if you alignment is not ideal. I find this measurement helpful if I can’t get a true doppler or oscillometric BP using a cuff due to excitement.
I agree that the LA:AO in your patient looks normal to mild.
I attached a Cornell weight normalized m-mode spreadsheet (using your m-mode measurements) that suggests that the patient’s LV chamber is enlarged in diastole with normal wall measurements in diastole. Stage B2 (LVE) with murmur.
Belated thanks Tom for your
Belated thanks Tom for your help with this one!
Hi, Just wanted to add to
Hi, Just wanted to add to EL’s comments.
When I have a patient like this in my practice, I tell the client that the patient is at higher risk for general anesthesia and I will use cardiac friendly sedation and anesthesia to minimize stress on the heart. With a mildly enlarged LA and no MV prolapse, then I would expect a good outcome. But with Mitral valve disease (MVD) my worry is that a chord may break which leads to sudden decompensation and possibly death. Very sad and unpredictable. So, in addition to RRR and chest films, I look carefully for a flailed leaflet or mitral valve prolapse to help me determine risk and long term prognosis.
There are other indices that can be measured to help you evaluate the severity of disease. Serum NT-proBNP concentration and selected Doppler echocardiographic variables such as mitral inflow measurements and E:IVRT ratio are helpful. See Schober JAVMA, Vol 239, No. 4, August 15, 2011.
Regarding systemic hypertension: If you are able to measure MR in the left apical view with your 6S then you can indirectly measure the minimum systolic BP in this dog. Whatever maxMR pressure gradient that you calculate, then the systolic BP is at least that much. It could be higher if you alignment is not ideal. I find this measurement helpful if I can’t get a true doppler or oscillometric BP using a cuff due to excitement.
I agree that the LA:AO in your patient looks normal to mild.
I attached a Cornell weight normalized m-mode spreadsheet (using your m-mode measurements) that suggests that the patient’s LV chamber is enlarged in diastole with normal wall measurements in diastole. Stage B2 (LVE) with murmur.
Belated thanks Tom for your
Belated thanks Tom for your help with this one!
You would expect a well
You would expect a well compensated MI to have an elevated FS. I would be a bit more worried if it was in the normal range.
You would expect a well
You would expect a well compensated MI to have an elevated FS. I would be a bit more worried if it was in the normal range.
yes compensated mr should
yes compensated mr should have an elevated FS% as this is the way it compensates. If the fs% is not elevated in these cases I recheck my measurements to be sure I didnt measure wrong.
yes compensated mr should
yes compensated mr should have an elevated FS% as this is the way it compensates. If the fs% is not elevated in these cases I recheck my measurements to be sure I didnt measure wrong.