- 9 year old MN Boston
- Hx of severe cholangiohepatitis dx by internist in spring 2014. VPCs noted May 2014 but no treatment at the time. The dog never had a heart murmur.
- Dog was being treated with actigall and liver protocol (don’t know the details, but assume samE and liver diet)
- Acute onset of yelping then severely ADR
- EKG is posted, v tach vs. wide complex SVT
- Blood work normal (including lytes) except for ALT of 131
- Rads NSF
- 9 year old MN Boston
- Hx of severe cholangiohepatitis dx by internist in spring 2014. VPCs noted May 2014 but no treatment at the time. The dog never had a heart murmur.
- Dog was being treated with actigall and liver protocol (don’t know the details, but assume samE and liver diet)
- Acute onset of yelping then severely ADR
- EKG is posted, v tach vs. wide complex SVT
- Blood work normal (including lytes) except for ALT of 131
- Rads NSF
- Prior to ultrasound, dog was treated with 4 mg/kg bolus of lidocaine to no effect. After ultrasound, dog was treated with another bolus of lidocaine, procainamide, diltaizem and propranolol with no effect. The dog then died during propofol prior to electric cardioversion.
- QUESTION: I am curious whether you guys think the previous VPCs and conversion to v tach could be related to the changes seen in the gall bladder wall and area of cbd, or whether this looks primarily cardiac? I am also interested to know whether you think the subjective dilation of the atria (I think?) is secondary to the arrythmia or primary.
Comments
The edematous Gb is likely
The edematous Gb is likely from the hepatic passive congestion as the cvc and hv are dilated and gb edema forms first then ascites as progression occurs. The RV/RA systolic dysfunction is present from the tachyarrythmia and likely underlying cardiac disease or effector action from systemic disease or myocarditis.
Re the ECG:It looks like V-Tach to me but I defer to Peter on ECG 🙂
Did you happen to try a vagal maneuver for SVT?
The edematous Gb is likely
The edematous Gb is likely from the hepatic passive congestion as the cvc and hv are dilated and gb edema forms first then ascites as progression occurs. The RV/RA systolic dysfunction is present from the tachyarrythmia and likely underlying cardiac disease or effector action from systemic disease or myocarditis.
Re the ECG:It looks like V-Tach to me but I defer to Peter on ECG 🙂
Did you happen to try a vagal maneuver for SVT?
I was not primary doc on this
I was not primary doc on this case so I don’t know if any vagal maneuvers were attempted. Precordial thump had no effect, nor did any meds.
Questions
1. Since this dog had a history of cholecystitis and cholangiohep, is there anyway to tell whether the gb issues are primary (recurrence of dx) or secondary to heart?
2. When a heart is barely contracting due to v tach like this, how can you assess whether there is underlying heart disease? The Doppler picked up so much noise I couldn’t get any read of regurg but the valves sure didn’t look myxomatous and no hx of heart murmur. Had a terrible time getting any views due to the resp distress.
3. The dog had no pulm edema on rads – clear lungs. Would you have reached for any different drugs? We do not have adenosine or Amiodarone inj.
Thanks for all the help. This is post mortem but at least we can gain something from this poor dogs disease!
One more thing: dog had pos murphys in right cranial abd, repeatable
I was not primary doc on this
I was not primary doc on this case so I don’t know if any vagal maneuvers were attempted. Precordial thump had no effect, nor did any meds.
Questions
1. Since this dog had a history of cholecystitis and cholangiohep, is there anyway to tell whether the gb issues are primary (recurrence of dx) or secondary to heart?
2. When a heart is barely contracting due to v tach like this, how can you assess whether there is underlying heart disease? The Doppler picked up so much noise I couldn’t get any read of regurg but the valves sure didn’t look myxomatous and no hx of heart murmur. Had a terrible time getting any views due to the resp distress.
3. The dog had no pulm edema on rads – clear lungs. Would you have reached for any different drugs? We do not have adenosine or Amiodarone inj.
Thanks for all the help. This is post mortem but at least we can gain something from this poor dogs disease!
One more thing: dog had pos murphys in right cranial abd, repeatable
1. There is no absolute
1. There is no absolute way of saying cholecystitis vs passive congestion edema wihtout a cholecystocentesis but the Gb looks clean and just edematous and with the dfilated hv and cvc I’m betting edema here.
2. tachyarrythmia like this drops the fs% 8-10+ points… if you ever echo an arrhythmia and look at fs% on the sinus beat and then fs% on the ectopic beat you will see a significant fs% drop then look at the fs% during a paroxysmal tachicardia and you will know exactly why peripheral vascular beds are hypoxic. Since this dog had no chf on rads im thinking primary arrythmagenic disease and not primary CHF. When you have CHF with arrythmia you treat the volume overload and most arrythmias resolve or are more manageable once you get 02 to th emyocardium and releive the myocardial stretch. This is more like boxer cmy where you have them die form lethal arrythmia way more often than having them reach volume overload and DCM-like chf. This is why this case screams some sort of myocarditis to me. Would be interesting to Bx the myocardium here.
3. I leave that to Peter on med options.
On the + Murphy was that on the GB specifically or elsewhere like the panc or referred back pain
1. There is no absolute
1. There is no absolute way of saying cholecystitis vs passive congestion edema wihtout a cholecystocentesis but the Gb looks clean and just edematous and with the dfilated hv and cvc I’m betting edema here.
2. tachyarrythmia like this drops the fs% 8-10+ points… if you ever echo an arrhythmia and look at fs% on the sinus beat and then fs% on the ectopic beat you will see a significant fs% drop then look at the fs% during a paroxysmal tachicardia and you will know exactly why peripheral vascular beds are hypoxic. Since this dog had no chf on rads im thinking primary arrythmagenic disease and not primary CHF. When you have CHF with arrythmia you treat the volume overload and most arrythmias resolve or are more manageable once you get 02 to th emyocardium and releive the myocardial stretch. This is more like boxer cmy where you have them die form lethal arrythmia way more often than having them reach volume overload and DCM-like chf. This is why this case screams some sort of myocarditis to me. Would be interesting to Bx the myocardium here.
3. I leave that to Peter on med options.
On the + Murphy was that on the GB specifically or elsewhere like the panc or referred back pain
I did an mmode on this (too
I did an mmode on this (too big to post)…there were NO sinus beats here, so when you say to compare – there was nothing to compare to. It is interesting the extent of the atrial dilation secondary to the arrhythmia.
The other question here is: should the VPCs have been somehow treated months ago before becoming v tach? If there was no cardiac murmur, and the pathology was myocardial, how would you proceed with treatment?
Could have been panc but I didn’t notice much pancreatic pathology. What do you think about the hyperechoic fat around the cbd and neck of the gb? Artifact from the edema?
I did an mmode on this (too
I did an mmode on this (too big to post)…there were NO sinus beats here, so when you say to compare – there was nothing to compare to. It is interesting the extent of the atrial dilation secondary to the arrhythmia.
The other question here is: should the VPCs have been somehow treated months ago before becoming v tach? If there was no cardiac murmur, and the pathology was myocardial, how would you proceed with treatment?
Could have been panc but I didn’t notice much pancreatic pathology. What do you think about the hyperechoic fat around the cbd and neck of the gb? Artifact from the edema?
The fat is ill-defined but
The fat is ill-defined but you get that in ascites about to form. Pancreatic edema would be interesting to see becauyse it looks different than pancreatitis and may help. Do you have a still of the right panc?
The fat is ill-defined but
The fat is ill-defined but you get that in ascites about to form. Pancreatic edema would be interesting to see becauyse it looks different than pancreatitis and may help. Do you have a still of the right panc?
Eric – I just posted the
Eric – I just posted the video I have of the duodenum (see above). Sorry I didn’t take a right panc still. Dog was pretty unstable and I was just trying to get in and out.
Eric – I just posted the
Eric – I just posted the video I have of the duodenum (see above). Sorry I didn’t take a right panc still. Dog was pretty unstable and I was just trying to get in and out.
The fat is ill-defined there
The fat is ill-defined there I would bet thats the + Murphy and so ascites forming there so the ill-defined fat is real and likely minor inflammation. Infectious maybe on this guy affecting the myocardium panc and maybe the GB?
The fat is ill-defined there
The fat is ill-defined there I would bet thats the + Murphy and so ascites forming there so the ill-defined fat is real and likely minor inflammation. Infectious maybe on this guy affecting the myocardium panc and maybe the GB?
So interesting. Thanks so
So interesting. Thanks so much for all your input. Would love to hear what Peter has to say about meds to reach for in the future. Am bummed that we couldn’t help this boy.
So interesting. Thanks so
So interesting. Thanks so much for all your input. Would love to hear what Peter has to say about meds to reach for in the future. Am bummed that we couldn’t help this boy.
The Art of Veterinary
The Art of Veterinary Medicine….
The Art of Veterinary
The Art of Veterinary Medicine….
One more question, sorry!
On
One more question, sorry!
On that first 4 chamber view of the heart, there’s an area in the atrial septum that appears to be thin and sort of flopping around. What is this?
One more question, sorry!
On
One more question, sorry!
On that first 4 chamber view of the heart, there’s an area in the atrial septum that appears to be thin and sort of flopping around. What is this?
I’m seeing horizontal
I’m seeing horizontal flopping linear atrial septum at 3 cm depth and vertical flopping septal TV leaflet at 2 cm depth and MV at 4 cm depth.
I’m seeing horizontal
I’m seeing horizontal flopping linear atrial septum at 3 cm depth and vertical flopping septal TV leaflet at 2 cm depth and MV at 4 cm depth.
That first flopping linear
That first flopping linear atrial septum at 3 cm depth…what is that? It has almost a paradoxical movement…
That first flopping linear
That first flopping linear atrial septum at 3 cm depth…what is that? It has almost a paradoxical movement…
Looks like heart based fat at
Looks like heart based fat at the pulmonary vein entrance into the LA
Looks like heart based fat at
Looks like heart based fat at the pulmonary vein entrance into the LA