Hi everyone, need some help on this case.
3 year old, male desexed greyhound with 4/6 mumur. No clinical signs, no ascites. Echocardiogram was requested as hoping to get this dog rehomed.
The Echocardiogram seems to indicated tricuspid dysplasia. However, there are mild changes on the measurements; enlarged atrium, decreased LVIDd, decrease LVPWd and low fractional shortening(25%). There is no mitral regurgitation, no pulmonary insufficiency and both pulmonary and aortic flow is normal ( <2m/s).
Cornell Normalized Reference Ranges:
Hi everyone, need some help on this case.
3 year old, male desexed greyhound with 4/6 mumur. No clinical signs, no ascites. Echocardiogram was requested as hoping to get this dog rehomed.
The Echocardiogram seems to indicated tricuspid dysplasia. However, there are mild changes on the measurements; enlarged atrium, decreased LVIDd, decrease LVPWd and low fractional shortening(25%). There is no mitral regurgitation, no pulmonary insufficiency and both pulmonary and aortic flow is normal ( <2m/s).
Cornell Normalized Reference Ranges:
95%CI
LVIDd 1.26 (1.27-1.85)
LVPWd 0.61 ( 0.29-0.6)
Left atrium 1.11 (0.63-0.96)
TR velocity was measured `2.6m/s making PG 27.5mmhg.
Questions:
1. is it safe to assumed dog doesn’t have pulmonary hypertension or would you still suspect it due to the under-estimation of pulse wave doppler
2. Should I be concerned about the changes on the left side?
3. When would you start medicating patients with tricuspid dysplasia?
Thank you all!
Comments
OK- Ill put my 2 cents in
OK- Ill put my 2 cents in here.
1. Right ventricular pressure is closer to 42 mmHg (and that is if you are not underestimating the TR jet). IMO the R atrium is grossly dilated which means its pressure is probably closer to 15 mmHg. If you add 27 + 15 then R ventricular pressure is probably closer to 42 mmHg. This would indicate moderate pulmonary hypertension.
2. I would be more concerned about the changes in the R side of the heart. L side is underperfused because of the R sided changes. Hepatic veins dilated? According to your picture the LA appears to be dilated when you calculate using the “June Boon” method<1.13)- but when I look at your 2D images in the 3rd cine loop the L atrium is not dilated when measured against the Aorta (<1.7).
3. I would start treatment if this were my case.
Now we can wait for the experts to jump in here
OK- Ill put my 2 cents in
OK- Ill put my 2 cents in here.
1. Right ventricular pressure is closer to 42 mmHg (and that is if you are not underestimating the TR jet). IMO the R atrium is grossly dilated which means its pressure is probably closer to 15 mmHg. If you add 27 + 15 then R ventricular pressure is probably closer to 42 mmHg. This would indicate moderate pulmonary hypertension.
2. I would be more concerned about the changes in the R side of the heart. L side is underperfused because of the R sided changes. Hepatic veins dilated? According to your picture the LA appears to be dilated when you calculate using the “June Boon” method<1.13)- but when I look at your 2D images in the 3rd cine loop the L atrium is not dilated when measured against the Aorta (<1.7).
3. I would start treatment if this were my case.
Now we can wait for the experts to jump in here
Nice post! But we try to
Nice post! But we try to minimize to a few stills and videos for the forum as its otherwise a telemed consultation but I understand the complexity of the question so this is fine and great image set! Just want to be fair to the others. Please see in read on the upper left for clarification.
I”m not seeing a dilated LA either if you look at the atrial septum it is flat and subjectively the LA looks normal to me. I usually don’t treat these guys til ex intollerance is an issue or emerging right chf is present and I measure cvc/ao ratio and hepatic veins:portal vein ratio … both should be 1:1 (unpublished data love to do a study but no time). As the right side fails the cvc and hepatic veins dilate (domitor mimics this) and then ascites forms.
Here is the latest from unpublished curbside guide info on tricuspid displasia (Modler Lobetti Frank and myself) Its in last editing fyi:)
http://sonopath.com/products
Tricuspid Dysplasia
Description: Tricuspid dysplasia (TD) accounts for 3.1-7.5 % of congenital diseases in dogs; it is also sometimes found in cats. Predisposed breeds include the Labrador, Golden Retriever, Great Dane, German Shepherd, Irish Setter, and Boxer, as well as the Chartreux cat.
Typical characteristics of TD include:
Regional or diffuse thickening of the valvular leaflets
Too short or missing chordae tendinae
Dysplasia and hypertrophy of the papillary muscles
Leaflets fixed to the septum
Tricuspid insufficiency
Ebstein’s anomaly is a congenital heart defect and a form of TD. It is characterized by an atrialized right ventricle in which the septal and posterior leaflets of the tricuspid valve are displaced toward the apex of the right ventricle, resulting in tricuspid insufficiency. This defect has been identified on chromosome 9.
Clinical Presentation:
Incidental finding (heart murmur without clinical signs)
Palpable precordial thrill may be present at the right heart base
Ascites (typically develops later on, if at all)
Atrial fibrillation (most patients with ascites due to TD develop atrial fibrillation)
It should be noted that many patients remain asymptomatic for years.
Diagnostics:Radiographic changes include right atrial and possibly right ventricular enlargement, as well as a dilated caudal thoracic vena cava, especially when right-sided congestive heart failure (CHF) occurs. Echocardiography will typically reveal right atrial and ventricular dilation, possible hypertrophy of the right ventricle, tricuspid insufficiency (velocity > 2.8 m/sec), and/or pulmonic insufficiency (velocity > 2.2 m/sec, which is consistent with pulmonary hypertension).
Treatment: No treatment is indicated if the right ventricle and atrium are not severely enlarged. Beginning treatment before the onset of clinical signs is controversial. In cases where ascites is present, one should conduct an abdominocentesis, which can be repeated, as needed, and administer pimobendan (0.25 mg/kg BID), enalopril (0.5 mg/kg PO Q12-24hr) or benazopril (0.25-0.5 mg/kg PO Q12-24hr), spironolactone (2-4mg/kg BID), and furosemide (2-3 mg/kg PO Q12-24hr). In cases of atrial fibrillation/supraventricular tachyarrythmia, one should give digoxin (0.005 mg/kg BID) or diltiazem (0.5-2mg/kg TID).
Prognosis: The prognosis depends on the severity of the condition; however, even severely affected dogs with early onset right-sided CHF can usually live for quite a long time.
References:
HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Chetboul+V%22” Chetboul V, HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Tran+D%22” Tran D, HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Carlos+C%22” Carlos C, et al. Congenital malformations of the tricuspid valve in domestic carnivores: a retrospective study of 50 cases. Schweizer Archiv fur Tierheilkunde 2004;146:265-75.
de Madron E, Kadish A, Spear JF, et al. Incessant atrial tachycardias in a dog with tricuspid dysplasia. Clinical management and electrophysiology. J Vet Intern Med 1987;1:163-69.
Famula TR, Siemens LM, Davidson AD, et al. Evaluation of the genetic basis of tricuspid valve dysplasia in Labrador Retrievers. Am J Vet Res 2002;63:816-20.
HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Hoffmann+G%22” Hoffmann G, HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Amberger+CN%22” Amberger CN, HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Seiler+G%22” Seiler G, et al. Klinik für kleine Haustiere der Universität Bern.
Tricuspid valve dysplasia in fifteen dogs. Schweizer Archiv fur Tierheilkunde 2000;142:268-77.
Johnson L, Boon J, Orton EC. Clinical characteristics of 53 dogs with Doppler-derived evidence of pulmonary hypertension: 1992-1996. J Vet Int Med 1999;13(5):440-47.
HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Liu+SK%22” Liu SK, HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Tilley+LP%22” Tilley LP. Dysplasia of the tricuspid valve in the dog and cat. J Am Vet Med Ass 1976;169:623-30.
Oliveira P, Domenech O, Silva J, et al. Retrospective review of congenital heart disease in 976 dogs. J Vet Int Med2011;25:477-83.
Tidholm A. Retrospective study of congenital heart defects in 151 dogs. J Small Anim Prac 1997;3:94-98.
Thank you!! Exactly what I
Thank you!! Exactly what I needed. Much appreciated:)
Nice post! But we try to
Nice post! But we try to minimize to a few stills and videos for the forum as its otherwise a telemed consultation but I understand the complexity of the question so this is fine and great image set! Just want to be fair to the others. Please see in read on the upper left for clarification.
I”m not seeing a dilated LA either if you look at the atrial septum it is flat and subjectively the LA looks normal to me. I usually don’t treat these guys til ex intollerance is an issue or emerging right chf is present and I measure cvc/ao ratio and hepatic veins:portal vein ratio … both should be 1:1 (unpublished data love to do a study but no time). As the right side fails the cvc and hepatic veins dilate (domitor mimics this) and then ascites forms.
Here is the latest from unpublished curbside guide info on tricuspid displasia (Modler Lobetti Frank and myself) Its in last editing fyi:)
http://sonopath.com/products
Tricuspid Dysplasia
Description: Tricuspid dysplasia (TD) accounts for 3.1-7.5 % of congenital diseases in dogs; it is also sometimes found in cats. Predisposed breeds include the Labrador, Golden Retriever, Great Dane, German Shepherd, Irish Setter, and Boxer, as well as the Chartreux cat.
Typical characteristics of TD include:
Regional or diffuse thickening of the valvular leaflets
Too short or missing chordae tendinae
Dysplasia and hypertrophy of the papillary muscles
Leaflets fixed to the septum
Tricuspid insufficiency
Ebstein’s anomaly is a congenital heart defect and a form of TD. It is characterized by an atrialized right ventricle in which the septal and posterior leaflets of the tricuspid valve are displaced toward the apex of the right ventricle, resulting in tricuspid insufficiency. This defect has been identified on chromosome 9.
Clinical Presentation:
Incidental finding (heart murmur without clinical signs)
Palpable precordial thrill may be present at the right heart base
Ascites (typically develops later on, if at all)
Atrial fibrillation (most patients with ascites due to TD develop atrial fibrillation)
It should be noted that many patients remain asymptomatic for years.
Diagnostics:Radiographic changes include right atrial and possibly right ventricular enlargement, as well as a dilated caudal thoracic vena cava, especially when right-sided congestive heart failure (CHF) occurs. Echocardiography will typically reveal right atrial and ventricular dilation, possible hypertrophy of the right ventricle, tricuspid insufficiency (velocity > 2.8 m/sec), and/or pulmonic insufficiency (velocity > 2.2 m/sec, which is consistent with pulmonary hypertension).
Treatment: No treatment is indicated if the right ventricle and atrium are not severely enlarged. Beginning treatment before the onset of clinical signs is controversial. In cases where ascites is present, one should conduct an abdominocentesis, which can be repeated, as needed, and administer pimobendan (0.25 mg/kg BID), enalopril (0.5 mg/kg PO Q12-24hr) or benazopril (0.25-0.5 mg/kg PO Q12-24hr), spironolactone (2-4mg/kg BID), and furosemide (2-3 mg/kg PO Q12-24hr). In cases of atrial fibrillation/supraventricular tachyarrythmia, one should give digoxin (0.005 mg/kg BID) or diltiazem (0.5-2mg/kg TID).
Prognosis: The prognosis depends on the severity of the condition; however, even severely affected dogs with early onset right-sided CHF can usually live for quite a long time.
References:
HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Chetboul+V%22” Chetboul V, HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Tran+D%22” Tran D, HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Carlos+C%22” Carlos C, et al. Congenital malformations of the tricuspid valve in domestic carnivores: a retrospective study of 50 cases. Schweizer Archiv fur Tierheilkunde 2004;146:265-75.
de Madron E, Kadish A, Spear JF, et al. Incessant atrial tachycardias in a dog with tricuspid dysplasia. Clinical management and electrophysiology. J Vet Intern Med 1987;1:163-69.
Famula TR, Siemens LM, Davidson AD, et al. Evaluation of the genetic basis of tricuspid valve dysplasia in Labrador Retrievers. Am J Vet Res 2002;63:816-20.
HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Hoffmann+G%22” Hoffmann G, HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Amberger+CN%22” Amberger CN, HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Seiler+G%22” Seiler G, et al. Klinik für kleine Haustiere der Universität Bern.
Tricuspid valve dysplasia in fifteen dogs. Schweizer Archiv fur Tierheilkunde 2000;142:268-77.
Johnson L, Boon J, Orton EC. Clinical characteristics of 53 dogs with Doppler-derived evidence of pulmonary hypertension: 1992-1996. J Vet Int Med 1999;13(5):440-47.
HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Liu+SK%22” Liu SK, HYPERLINK “http://europepmc.org/search?page=1&query=AUTH:%22Tilley+LP%22” Tilley LP. Dysplasia of the tricuspid valve in the dog and cat. J Am Vet Med Ass 1976;169:623-30.
Oliveira P, Domenech O, Silva J, et al. Retrospective review of congenital heart disease in 976 dogs. J Vet Int Med2011;25:477-83.
Tidholm A. Retrospective study of congenital heart defects in 151 dogs. J Small Anim Prac 1997;3:94-98.
Thank you!! Exactly what I
Thank you!! Exactly what I needed. Much appreciated:)
Glad to be of help! This is a
Glad to be of help! This is a great exemplary post on a solid topic altogether and very informative. this is what I had in mind for the forum. Thank you for participating!
Glad to be of help! This is a
Glad to be of help! This is a great exemplary post on a solid topic altogether and very informative. this is what I had in mind for the forum. Thank you for participating!