- 9 year old FN Weimeraner with CHF, degenerative mitral valve disease, severe mtiral regurgitation, left atrial enlargement and atrial fibrillation with large volume abdominal effusion
- Weight loss, decreased appetite and loose faeces – decreased albumin, globulin and cholesterol
- There was also pulmonic regurgitation and tricuspid regurgitation (but not at level of pulmonary hypertension) but the right sided chambers seemed normal in size to me
- Hepatic venous distension but abdominal scan otherwise unremarkable
- 9 year old FN Weimeraner with CHF, degenerative mitral valve disease, severe mtiral regurgitation, left atrial enlargement and atrial fibrillation with large volume abdominal effusion
- Weight loss, decreased appetite and loose faeces – decreased albumin, globulin and cholesterol
- There was also pulmonic regurgitation and tricuspid regurgitation (but not at level of pulmonary hypertension) but the right sided chambers seemed normal in size to me
- Hepatic venous distension but abdominal scan otherwise unremarkable
- Is it secondary right sided heart failure that is causing the abdominal effusion? Is the right atrium enlarged?
- I suspect GI signs secondary to poor absorption from ascites?
- Thank you in advance
Comments
Hello!
Apologies for the
Hello!
Apologies for the delayed response. For some reason, I could not view the videos but the pictures and history may be sufficient to offer some insight.
The left atrium is huge and consistent with left side volume overload. Triple therapy with Vetmedin, Enalapril, Lasix +/- Spironolactone are warranted. These medications are probably being given already. A beta blocker or calcium channel blocker are warranted for the atrial fibrillation.
The right heart doesnt look enlarged and without definitive pulmonary hypertension, the right heart does not appear to be the cause of the ascites. Possibilities for the ascites may include:
1. Concurrent PLE in light of the reported decreased albumin, globulin and cholesterol which fit with PLE. If the albumin levels are <1.5, ascites secondary to the decreased albumin is probable.
2. Arrhythmia induced cardiomyopathy. Atrial fibrillation and tachycardia secondary to left atrial enlargement can result in systolic and diastolic dysfunction or abnormal synchrony of the the heart contractions. The addition of the beta blocker or calcium channel blocker should help with thjis if its present.
If PLE is suspected, some or all of the following protocol may be given:
OBJECTIVE: keep albumin levels > 2 g/dl, avoid thromboembolism and cavitary effusions, monitor concurrent PLN (Wheaton Terrier PLE/PLN) and liver disease:
Plasma 10 mL / kilogram IV over 4 hours
Or Human albumin 2 ml/kg/h over 10 hours. Total daily volume 20.l/kg/day
And Colloids/Hetastarch
10 to 20 mL per kilogram per day and dogs
10 to 15 mL per kilogram per day cats
(Can bolus first 1/3 of dose over 15 minutes)
& maintain on LRS maintenance otherwise.
Metronidazole (10-20 mg/kg po bid)
Famotidine 1 mg/kg Iv Im po dc Sid /bid
Sucralfate 0.5-1 g po tid dogs, 0.5 g bid cats in slurry Or Misoprostol 1-5 ug/kg po tid
Diet: Highly digestible high quality protein, low fiber, low fat diet (< 15% of dry matter). Hydrolyzed protein or novel protein. Purina HA or Royal Canine HP or similar.
Prednisone or prednisolone 2 mg/kg bid x 3-5 days then 2 mg/kg sid. Chlorambucil in refractive severe IBD/alimentary lymphoma cases (monitor cbc for rare bone marrow suppression) 4 mg/m2 Q 24-48 hours.
Cobalamine (B12) 250-1500 ug/dog weekly x 6 weeks.
Calcium supplementation if necessary.
Aspirin 0.5-1 mg/kg/day or Clopidrel (Plavix) 1-5 mg/kg/day.
Tough case!
Yes but watch on the plasma
Yes but watch on the plasma expanders as will overload the heart further. Need clean TR velocities as Im suspecting right chf causing ascites here especially if albumin is > 1.5 an dyour first video has HV and CVC dilation at the liver.diaphragm SDEp posiiton 12. You dont necessarily need RA enlargement to have right chf. The HV are congested which suggests right chf or obstructive caval disease so look for a TR jet above 3.5 or higher. I would tx triple therapy on the heart first and see what the ascites does and if PHT is present then add sildenafil
Thanks to you both. Yes the
Thanks to you both. Yes the albumin was not low enough to be causing the ascites.
The fact that the right atrium is not enlarged makes it tricky but I did believe it to be R- CHF due to HV congestion.
yes these can be tricky and
yes these can be tricky and ive seen this happen wiht sudden onset right chf most often like when you get PTE or something similar increasing pulmonary vascular pressures rapidly.