I am working on improving my echo skills with our new 6S probe. I am just getting used to continuous wave doppler (vs. just being able to use pulse wave in the past) and trying to get comfortable rule out pulmonary hypertension. I live at 5K, so a frequent thing to rule out.
I am working on improving my echo skills with our new 6S probe. I am just getting used to continuous wave doppler (vs. just being able to use pulse wave in the past) and trying to get comfortable rule out pulmonary hypertension. I live at 5K, so a frequent thing to rule out.
I have several questions about the case attached. She is a 6 year old FS Boston. She had an episode of vomiting and what sounds like reverse sneezing when owner said thought it looked like she couldn’t breath – rads showed mild interstitial pattern and right heart enlargement. Radiologist recommended HWT and echo. HWT still not performed (did not see any evidence of HW on echo). No other symptoms (other than skin issues)
I know this is just a snippet of info on this case, but wondering if you could comment on technique and on the velocities I got for tricuspid and pulmonary insufficiency – both lower than what would expect w/ PH, so I am assuming trivial/”normal”. (I did realize in hindsight I should have increased the PRF on the tricuspid CWD, but it looks like the regurgitation does taper out). What suprised me was that her left ventricle was significantly enlarged. The left atria was mildly enlarged w/ a normal La:Ao and some mild to moderate degenerative changes to the septal mitral leaflet w/o any regurgitation on color or doppler that I could capture (no murmur on auscultation). I did not think the right heart looked big.
Would you be willing to comment on the provided images and if you have seen DCM in Bostons? I read on VIN that it can be associated w/ taurine deficiency in this breed, but rare. I just am worried I am missing something.
Ugh – just realized my two videos I would like to submit are 31 MB – is there another way I can submit them or an easy way to decrease the file size?
Comments
The thing about the right
The thing about the right side cardiac doppler on TR and PR most larger breeds have physiologic PR and TR and I don’t personally even report it til > 1.5 m/sec. TR jet is much easier to quantify than PR but PHT not noted til > 2.8 m/sec for TR and 2.4 for PR and clinical signs I have never seen until TR is > 3.5 and some are non clinical even at 4 m/sec. No consensus here. A quick check I and my team do is check the abdominal cvc and ao right at the diaphragm (intrahepatic right intercostal shunt hunt view) and it should be 1:1. If the CVC is big and my TR jet isnt high I’m working reall hard to find a miniscule high velocity jet > 3 m/sec to justify the cvc dilation because they are easy to miss especially when the TV is structurally solid. Its easy when the TV is vegetative and prolapsing and such as the TR band is wide and easy target. So if Im chasing a TR jet and not finding it I go to the abdomen and check the CVC, AO and HVC and if they are normal the TR jet means nothing as even if its there its well compensated. I would love to do a study on this of progresstion of right HF and TR velocities and cvc ao ratio but no time of course but I find it useful in practice to get through my exam and move on. Hope this helps wiht the right side issues
Thank you for the reply.
Thank you for the reply. VERY helpful and I will plan to look at the CVC tomorrow. The title of your post makes me wonder if you put more trust in velocities measured from left views? Do you find it easier to search for small TR and PR jets from the left? Or is it a positioning thing making physiologic regurg more evident on the right? I had a really tough time for some reason getting the left cranial views in this patient (usual about the easiest views for me, but could just not get the PA to come in well).
I was able to upload the videos I mentioned previously with Kelly’s help. Just selected a the right sided pulmonary outflow and the left apical 4 chamber view to try to show overall impression of this patient in 2D. Any thoughts about Bostons and DCM or do you think I’m off track?
Well to answer your question
Well to answer your question and others I put together the downloadable lecture on the SDEP echo http://www.sonopath.com/products/downloadable
The right side of the heart I was referring to. I use what the SDEP protocol defines as position 2 with a right parasternal oblique that puts the TV apposition right next to the body wall minimizing potential for interference… any time you get a structure closer to the probe the more precise you will be and Doppler is no different. If that doesnt work, which for me is rare on that view, then I will use heart based view with the TV on the left at 10 oclock position. One or the other gives me what I need usually but I very rarely scan anything other than position 3 from the left which is the right auricle check but the patient is always on the right side as they hate getting flipped. keep them happy ont he right side and move around th eclock til you are done. the less opportunity you give them to move around the more they will be compliant to your echo. If your Doppler isnt clean then those downloadable lectures are ideal as well. I stioll learn things form them when I watch. The SDEP echo lecture explains all this so I of course recommend it:) We are planning a first quarter SDEP echo and cardiac pathology seminar in early 2016. Likely a ski meeting:)
Regarding Bostons and DCM I don;t know of a breed predisposition but I didn’t think that when I saw my first Labrador wiht it ion 2002 and then someone wrote it up so I think any breed can get it. But when an atypical breed gets DCM which your second video is very DCM-ish and certainly a pimobendan/triple therapy supplemented with Taurine – deficiency:) I think about potential for myocarditis especially wiht an arrythmia that he seems to have as well unless thats a video gremlin issue I see there.
Its just like when non valve breeds get valvular disease I think endocarditis because in NJ we have lots of bartonella and sometimes treating wiht clindamycin on these guys the vegetations go away:) So you may consider myocardiotis in dcm-ish presentations in non dcm breeds. Parvo myocarditis in puppies does exactly this:
http://sonopath.com/members/case-studies/cases/dilated-cardiomyopathy-dcm-syndrome-secondary-parvoviral-myocarditis
and then try searching “myocarditis” in the forum search and see an applicable array of cases:
http://sonopath.com/members/case-studies/search?page=2&text=myocarditis&species=All
Thank you so much, Eric.
Thank you so much, Eric. Very helpful. I am definitely interested in the echo lecture in ski country!
Is the triple therapy co-Q,
Is the triple therapy co-Q, carnitine and taurine? I’ve spoken w/ a local cardiologist in the past and she has also recommended taurine in the past. I was also thinking about fish oil and benazapril. Seems like the cardiologists are divided on when to start pimo, so maybe no right answer, but at least this is a small dog – last occult one I had was a good friend of mine making tech salary with a large dog :-(.
triple therapy is lasix,
triple therapy is lasix, ace-i, pimobendan to start along with taurine… then spironolactone is another step as well if you like it. I would go triple with taurine and reecho in a week comparing you la max and lv mmodes mostly
Sorry for yet another
Sorry for yet another question – I am often hesitant to start furosemide with minimal pulmonary changes, but assuming its ability to decrease preload in a case like this is the motivation?
Can’t thank you enough for your coaching – this is the best source of CE I can do on a regular basis amidst the chaos of life!
Clinical dcm wiht volume
Clinical dcm wiht volume overload standard tx is triple tx. Assuming epss > 0.8 in proper position, lvidd enlargement and LA enlargement (which can be mild in dobies for example) and fs% < 20 then triple tx is indicated and ensure taurine or thyroid of myocarditis isnt playing a role. Some cardiologists wait til wet lung but I think that has been going out of vogue over the years. When valve disease stage B2 is fair game for triple tx but there is no consensus on this. Whay I see int he field is erroneous measurements put a dog in B2 when he isnt so have to ensure propr angles and positions on La max la/ao and lv mmode and epss. Bottom line is for cardio the combinations of tx are all over th emap so my opinion surely wont agree wiht 60% of the population that would tx with 4 other protocols. I can only say what I have had success with. Peter and europeans have a high cost of ace-i so they tend to not use them as much but thats a reality issue and not necessarily a theoretical issue. Then you have all the ace-i studies that I wont get into but you can interpret them one way or another.
Hi Eric. Have more follow
Hi Eric. Have more follow up. The CVC looked ok on this dog in relation to Ao. The ECG shows a sinus sick syndrome. I am recommending thyroid testing (last done 3 years ago). Do you see any contraindication to starting the triple tx in light of the arrhythmia? She is not having fainting spells at this point and the HR is between 80-120.
Hmmm sick sinus is usually
Hmmm sick sinus is usually not an arrythmia from volume overload and it will cause dilation and retention and DCM-like presentation so I would look hard at the epss angles and likely needs a pacemaker. Sounds like you need the full image set of measurments analyzed as this is a complicated case. Other opption is cardio referral especially oif pacemaker is in order. This would be best for our telemed service as it sounds extensive and beyond the forum at this point. If interested just follow the steps from the home page on the telemed icon.
Thanks, Eric. I agree that I
Thanks, Eric. I agree that I would like the complete set reviewed or a rescan by a cardiologist to be sure as it does not seem straightforward. I’ll see where the owner wants to go with things.