Billy is a 12 year old Pomeranian with a grade 2-3/6 HSM. Chest X-rays indicate R sided heart enlargement. I suggested an echo to the owner and she agreed.
Billy is a 12 year old Pomeranian with a grade 2-3/6 HSM. Chest X-rays indicate R sided heart enlargement. I suggested an echo to the owner and she agreed.
When I did the echo I was able to confirm a mitral insufficiency but I was unable to confirm the right sided enlargement. On one of the Cine loops it appears there is turbulent pulmonary flow but doppler doesn’t confirm this. I could also not find a tricuspid regurgitation. Am I overestimating R sided enlargement on the x-rays? On the 4 chamber R parasternal it appears that the R side of the heart is normal. I have other images and cine loops if further clarification is needed.
Comments
The right atrium in 4
The right atrium in 4 chamber is 1:1 in your views with the left atrium and should be 2/3 the size of the left atrium so when the RA = LA especially when the LA is bigger than normal then by default the RA is big. The LA loook bordeline here so an RA=LA means right RA enlargement-mild. Not likely clinical but this will help in justifying a cranial waist enlargement on the rads but would need a TR doppler to assess for PHT and check the hepatic veins to see if congested. Cool mitral prolapse!
Here are some peter modler (http://sonopath.com/about/specialists/peter-modler-dvm-dipl-tzt) echo pearls that help the interpretation:
Peter’s Echo Pearls
2-d measurements taken from the inner edge and m-mode measurements are taken from the leading edge.
1. Normal echo interpretation concepts:
LVFW is 3.5 to 4.5 of LVIDd
RV is 1/3 of LV in 4-chamber view
RVFW is 1⁄2 of IVS or LVFW width
LV must be straight as is the Atrial Septum
RA must be < LA diameter
If all this is true then no hemodynamically significant problem will be present
with exception of arrhythmias.
1
Patient
to assess if the murmur is significant or not
M-mode must be performed form right parasternal 4-chamber and LV short axis view. The measurements must be similar. Don’t use 5-chamber view for dogs in m-mode.
PW Doppler used to find turbulence and local velocities, CW Doppler is used to find maximum velocities
Keep an eye on the frame rate, reduce the imaging depth as far as possible and reduce the sector angle as much as possible.
Reduce the line density to optimize the image and color flow.
The right atrium in 4
The right atrium in 4 chamber is 1:1 in your views with the left atrium and should be 2/3 the size of the left atrium so when the RA = LA especially when the LA is bigger than normal then by default the RA is big. The LA loook bordeline here so an RA=LA means right RA enlargement-mild. Not likely clinical but this will help in justifying a cranial waist enlargement on the rads but would need a TR doppler to assess for PHT and check the hepatic veins to see if congested. Cool mitral prolapse!
Here are some peter modler (http://sonopath.com/about/specialists/peter-modler-dvm-dipl-tzt) echo pearls that help the interpretation:
Peter’s Echo Pearls
2-d measurements taken from the inner edge and m-mode measurements are taken from the leading edge.
1. Normal echo interpretation concepts:
LVFW is 3.5 to 4.5 of LVIDd
RV is 1/3 of LV in 4-chamber view
RVFW is 1⁄2 of IVS or LVFW width
LV must be straight as is the Atrial Septum
RA must be < LA diameter
If all this is true then no hemodynamically significant problem will be present
with exception of arrhythmias.
1
Patient
to assess if the murmur is significant or not
M-mode must be performed form right parasternal 4-chamber and LV short axis view. The measurements must be similar. Don’t use 5-chamber view for dogs in m-mode.
PW Doppler used to find turbulence and local velocities, CW Doppler is used to find maximum velocities
Keep an eye on the frame rate, reduce the imaging depth as far as possible and reduce the sector angle as much as possible.
Reduce the line density to optimize the image and color flow.
EL or PM – maybe you can
EL or PM – maybe you can clarify my thinking on this case.
1. I have seen a large Mitral Regurg on this dog
2. Pulmonary spectral flow indicates a maximum velocity of 0.74 cm/sec- so pulmonic stenosis in not an issue
3. If the R atrium is enlarged as you say, I would suspect there is probably pulmonary hypertension secondary to the mitral valvular disease.
4. Why can’t I verify a tricuspid regurg. Am I just not seeing it? It there any other way you can explain the changes I am seeing.
Cine loop 3 is my attempt at CFI to verify the Tricuspid regurg. Are my settings off?
This dog is coming back on Friday and I will try to see if I missed a tricuspid regurg.
I hope I am making myself clear.
I am also adding the original chest x-rays. Is there not R sided heart enlargement here?
EL or PM – maybe you can
EL or PM – maybe you can clarify my thinking on this case.
1. I have seen a large Mitral Regurg on this dog
2. Pulmonary spectral flow indicates a maximum velocity of 0.74 cm/sec- so pulmonic stenosis in not an issue
3. If the R atrium is enlarged as you say, I would suspect there is probably pulmonary hypertension secondary to the mitral valvular disease.
4. Why can’t I verify a tricuspid regurg. Am I just not seeing it? It there any other way you can explain the changes I am seeing.
Cine loop 3 is my attempt at CFI to verify the Tricuspid regurg. Are my settings off?
This dog is coming back on Friday and I will try to see if I missed a tricuspid regurg.
I hope I am making myself clear.
I am also adding the original chest x-rays. Is there not R sided heart enlargement here?