Case Of the Month

Collapse and Cyanosis

It’s a clot! No it’s a thrombus! Or… maybe it’s a mass… What are those things messing with Tomie Timon’s Doppler in the pulmonic outflow tract in this echocardiogram?

Tomie Timon RDMS of Eugene, Oregon, shows us “what does this” with Dr. Peter Modler’s help from sunny AustriaJ. Oh yes the world is truly flat Mr. Friedman when veterinary diagnoses come from half way across the planet by means of an Oregon-Austrian connection.

Imaging by Tomie Timon RDMS, Animal Sounds Mobile Veterinary Ultrasound Service, Eugene, Oregon.

It’s a clot! No it’s a thrombus! Or… maybe it’s a mass… What are those things messing with Tomie Timon’s Doppler in the pulmonic outflow tract in this echocardiogram?

Imaging by Tomie Timon RDMS, Animal Sounds Mobile Veterinary Ultrasound Service, Eugene, Oregon.

History: An 11-year-old NM Golden retriever was presented for evaluation of two episodes of collapse and cyanosis. Additional history was that the patient is more lethargic than usual. Cardiac auscultation did not reveal any abnormalities and blood pressure was normal.

Comments

Special thanks to Dr. Nancy Johnson at The Veterinary Hospital, Eugene, OR for managing this case; and to Dr. Mark McConnell at Emergency Veterinary Hospital, Eugene for necropsy.

Clinical Differential Diagnosis

Pericardial effusion
Cardiomyopathy – hypertrophic, dilated
Myocarditis
Cardiac neoplasia
Pulmonic thrombo-embolic disease
Metabolic disease – anemia, met-hemoglobinemia

Sampling

Post mortem biopsy revealed marked lung congestion, right ventricular hypertrophy, and grade 3 fibrosarcoma of the pulmonary valve with attached thrombus.

Sonographic Differential Diagnosis

(Modler): The most remarkable abnormality is the presence of a mass or masses within the pulmonary artery and attached to the pulmonic valve. All masses have the same echogenicity and cause obstruction to flow which the consequence of right ventricular hypertrophy. Even though it cannot be ruled out that these masses are thrombi (but not septic thrombi because there is no history of fever) I would think that this is neoplasia (thrombosis usually causes pulmonary hypertension). One case of pulmonary artery leiomyosarcoma is mentioned in the veterinary literature, more can be found in human literature.

Obtaining a sample via catheter (snare) would be ideal If this is not possible then the only option would be r ight heart surgery (no cardioplegia necessary).

And I would recommend administration of Plavix or aspirin in this patient as a palliative measure and recheck sonogram weekly if no sampling is possible.