Response to Joe Sonographer regarding this cardiac case differentiating DCM from MR and myocardial insufficiency:
Note: The images reflect a follow up image set rechecking a colleagues prior report on this patient that indicated likely DCM. These images reflect a progression of MR and left atrial enlargement. the question is if this case is DCM or MR and myocardial insufficiency in the past that may have mimicked DCM at the first examination.
The Boon/Gordon echo courses in Dallas (Soundeklin) I went through back in the day with them they went over distinguishing DCM from MR with myocardial insufficiency. This is the summary from the courses and my own experience and added tidbits that regard this case and other similar scenarios.
1) You should never bring up DCM as a primary dx without a solid EPSS at 0.8 cm or higher in exact proper position.
“Clinical” DCM criteria LV dilation, epps >0.8 cm, FS near 22% or lower to head into failure or have clinical signs with DCM or even emerging DCM. This dog had MR and LA was big and LV was big but what the kicker here is that “big dog MR” is not like “small dog MR.” Big breeds don’t get high FS% like small breeds do. The 28% could be measurement of the LV being closer to the MV annulus as opposed to closer to the papillary (papillary is always more contractile) which is the technical reason I was discussing other than being potentially off line on the LV M-mode.
For example I saw a large breed Dobie x yesterday (images not shown) that was throwing PTE, had slight pericardial effusion but no mass or tamponade and was systemically sick and his EPSS was 0.6, LVIDd slightly big but very arrhythmagenic (which drops FS%) and systemic disease drops FS% and I measured 22% near the annulus and 36% near the papillary (but not on the papillary) Its a sectorial kinetic issue.
During an arrhythmia he was 22% and during normal systole 36%. When serious arrhythmias happen the FS% drops below 20% or so and they get syncope. Not the case in your dog with images here but just an example of what to keep in mind for other cases… but this Dobie that I saw yesterday, even being a Dobie, was not DCM. He was systemically sick with arrhythmagenic activity.
Other causes of fs% drop are arrhythmias, endocrine disease i.e Addisons, thyroid…, systemic disease of any type. So these things should always be put in the report as possibilities when you have a mildly depress fs% in any breed especially when above 25%. I don’t even mention DCM in the dx until 25% looms unless the other EPSS and LVIDd criteria are solidly there.
So here is the after the fact issue. In the echo shown by these image’s he is showing 36-44% FS, MR of 5.7 m/sec and some TR and chronic LAE mild. This is valvular disease in bigger breeds and when you saw him he had potential emerging myocardial insufficiency since the fs% is in the mid/high 20s and volume overload is present. But that is not the issue now as he worked himself out of whatever funk he was in without the meds that he couldn’t handle at the time and now is completely compensated without any minimal trace of DCM.
So:
Your Dx of “Evidence of early dilated cardiomyopathy.” This would be appropriate if LVIDd is big FS% under 25% and EPSS > 0.8 in good position (EPSS is always the closest measurement in perfect perpendicular fashion as it is easily skewed) and I would add ” “clinically compensated” or “emerging Left CHF” if the LA is big and there is a cough from mainstem bronchus impingement… that you couldn’t tell because there were no rads but if LA/AO is >1.4 in big dogs (June Boon method) then the cough could be cardiogenic.
So based on your numbers in the table in your report 5 months ago I would have worded it this way:
“MR with prominent LA and emerging myocardial insufficiency. Rule out concurrent systemic disease or endocrinopathy (i.e. hypothyroidism) and hypertension and potential taurine deficiency (optional). Potential for emerging DCM. cough may be partially cardiogenic and also have a respiratory component dependent on radiographic findings.”
This downplays the DCM reasoning but takes care of your reasoning should he develop into it later.
These are complicated cases to interpret no doubt. I wrestled with them in my developing time as well.
The dx can be solid like this:
“MR + Mild/Moderate LAE.” owing to the 6+ cm LA max size which is excessive for a Doberman.
Eric Lindquist DMV (Italy) DABVP
Cert. IVUSS
Director SE NJ Mobile Associates, Founder/CEO SonoPath.com
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