Sammy

 

HISTORY - Sammy is a 2 year old neutered male terrier mix.  A grade 5-6/6 heart murmur was ausculted by the referring DVM on a routine clinical exam.  There are no clinical signs at home but there appeared to be cyanosis when Sammy was restrained.

PHYSICAL EXAMINATION - Gingival mucous membranes were a normal pink color with capillary refill time < 2 seconds.  The arterial pulses were normal and synchronous.  The jugular veins were normal.   A IV-V/VI   (with associated thrill)   with a PMI ( point of maximal intensity ) at the left mid- thorax.   The murmur is poorly localized and there may be a thrill at the right lower thorax as well.The transient heart sounds ( S1, S2 ) were normal.    The heart rate was regularly irregular in association with respiration ( increasing rate with inspiration ) suggestive of normal sinus arrhythmia; sinus arrhythmia was somewhat excessive/pronounced.The apical impulse of the heart was mildly hyperdynamic and suggestive of a left ventricular "heave".   Abdominal palpation was normal.  Respiratory effort was normal.  Respiratory sounds were normal in all fields. 

 

 

 

 

 

ECHOCARDIOGRAPHY (M-MODE) RELATIVE RATIO INDICES

---------|-------|------*-- FWTd = 0.516 -- Fractional wall thickness - diastole
---------|-------|-----*--- FWAd = 0.765 -- Fractional wall area - diastole
---------|-------|---*----- FWTs = 0.735 -- Fractional wall thickness - systole
---------|-------|--*------ FWAs = 0.930 -- Fractional wall area - systole
---------|-------|*-------- FS = 0.481 -- Fractional shortening
---------|------*|--------- FDA = 0.730 -- Fractional change in chamber area
---------|---*---|--------- ASYM = 0.05 -- LV septal - free wall assymetry

ECHOCARDIOGRAPHY (M-MODE) BODY WEIGHT RATIO INDICES

---------|-------|--------* wWAs = 9.26 -- LV myocardial wall area, diastole  -  BW normalized
---------|-------|--------* wWAd = 8.46 -- LV myocardial wall area, diastole  -  BW normalized
---------|-------|--------* wWTd = 1.71 -- LV combined wall thickness, diastole - BW normalized
---------|-------|--------* wWTs = 2.32 -- LV combined wall thickness, systole -  BW normalized
---------|-------|--------* wLVWs = 1.23 -- LV wall thickness, systole  - BW normalized
---------|-------|--------* wLVWd = 0.84 -- LV wall thickness, diastole - BW normalized
---------|-------|--------* wIVSd = 0.88 -- Interventricular septum thickness, diastole - BW normalized
---------|-------|-------*- wIVSs = 1.09 -- Interventricular septum thickness, systole - BW normalized
---------|-------|------*-- wLVODs = 3.16 -- LV outer dimension, systole -  BW normalized
---------|-------|-----*--- wLVODd = 3.32 -- LV outer dimension, diastole -  BW normalized
---------|-------|---*----- wLA = 1.40 -- LA dimension - BW normalized
---------|-----*-|--------- wDA = 1.89 -- LV internal cross sectional area change  -  BW normalized
---------|-*-----|--------- wLVIDs = 0.84 -- LV internal dimension, systole  - BW normalized
---------|---*---|--------- wLVIDd = 1.61 -- LV internal dimension, diastole - BW normalized
 wAo = 1.23 -- Aortic dimension - BW normalized

ECHOCARDIOGRAPHY (2D)
Mitral dysplasia is present, seemingly with 4 LV papillary muscles.  The most cranial muscle is close to the left ventricular outflow tract and chordal attachments to this muscle are tethering the anterior mitral valve leaflet into the outflow tract resulting in severe/extreme stenosis.  The most caudal papillary muscle is also tethered to the interventricular septum and distraction of this muscle may be contributing to displacement of the anterior mitral leaflet into the outflow tract also.  At this severity of disease, the left ventricular hypertrophy also contributes to the stenosis.  Left ventricular endocardial echogenicity is increased, suggestive of replacement fibrosis secondary to ischemia. There is mild thickening of the mitral valve is well.

Left atrial size was moderate-markedly increased (not shown).  The left ventricular internal diastolic diameter was normal.The left ventricular internal systolic diameter was normal.  Left ventricular systolic function ( fractional shortening, end-systolic dimension) was at the upper limit of normal (equivocally increased).  Left ventricular "relative wall thickness" (FWTd, FWAd, RWTd) was markedly increased giving the appearance of marked hypertrophy.  Overall (combined free wall and septem), left ventricular wall thickness was extremely increased.  The interventricular septum ( diastole) was extremely increased and the left ventricular "free" wall was extremely increased in thickness.  An index of LV hypertrophy (wWAd) was extremely increased,  indicating true hypertrophy (secondary to LV outflow obstruction).  An index of LV stroke volume was normal.

DOPPLER ECHOCARDIOGRAPHY

Aortic ejection velocity was extremely increased consistent with aortic outflow obstruction (stenosis, dynamic obstruction).  Typical pressure gradients for  the left ventricular outflow tract were extremely increased indicating very severe stenosis  (> 100 mmHg gradient).   There was a great deal of variation in the pressure gradients;  this may be fortuitous in that it suggests a significant dynamic component of the stenosis which may allow a decrease in pressure gradient with appropriate beta-blocker therapy.  Individual ejections resulted in extreme  velocities as high as 8.5 m/sec corresponding to a pressure gradient of almost 300 mm Hg.
Pulmonic ejection velocity was normal.  The pressure gradient for the right ventricular outflow tract was normal.
---------|-------|--------* A_vmx  (m/sec) = 5.8 -- Aortic velocity max (m/sec)
---------|------*|--------- ME_dt (msec) = 113.354 -- Mitral E deceleration time (msec)
---------|----*--|--------- MA_vp (m/sec) = 0.623 -- Mitral A peak velocity (m/sec)
---------|--*----|--------- P_vmx (m/sec) = 1.0 -- Pulmonic velocity max (m/sec)
---------|--*----|--------- MEA_R = 1.278 -- Mitral E/A ratio
---------|----*--|--------- ME_vp (m/sec) = 0.796 -- Mitral E peak velocity (m/sec)
 ME_dr (m/sec^2) = 7.021 -- Mitral E deceleration rate (m/sec^2)
 P_pp (mmHg) = 4.2 -- Pulmonic peak gradient (mmHg)
 A_ppt (mmHg) = 134.445 -- Aortic peak gradient (mmHg)

THERAPEUTIC RECOMMENDATIONS
Atenolol was instituted in an attempt to relieve some of the dynamic component of the obstruction and decrease myocardial oxygen requirements as well as diminish the pressures developed within the myocardium.

 



RECHECK EXAMINATION 1/2 YEAR LATER

CV PHYSICAL EXAMINATION
Body condition score ( BCS ) was estimated at 5/9 ( normal ).  Gingival mucous membranes were a normal pink color with capillary refill time < 2 seconds.  The arterial pulses were normal and synchronous.  The jugular veins were normal.   A I-II/VI   systolic murmur was present   with a PMI ( point of maximal intensity ) at the right mid thorax ( tricuspid valve area).   The transient heart sounds ( S1, S2 ) were normal.    The heart rate was regularly irregular in association with respiration ( increasing rate with inspiration ) suggestive of normal sinus arrhythmia.  The apical impulse of the heart was within normal limits.    Abdominal palpation was normal.  Respiratory effort was normal.  Respiratory sounds were normal in all fields.

 

 

 

ECHOCARDIOGRAPHY (M-MODE) RELATIVE RATIO INDICES

---------|-------|--*------ FWTd = 0.455 -- Fractional wall thickness - diastole
---------|-------|--*------ FWAd = 0.703 -- Fractional wall area - diastole
---------|------*|--------- FWTs = 0.634 -- Fractional wall thickness - systole
---------|------*|--------- FWAs = 0.866 -- Fractional wall area - systole
---------|----*--|--------- ASYM = 0.18 -- LV septal - free wall assymetry
---------|---*---|--------- FS = 0.342 -- Fractional shortening
---------|---*---|--------- FDA = 0.567 -- Fractional change in chamber area

ECHOCARDIOGRAPHY (M-MODE) BODY WEIGHT RATIO INDICES

---------|-------|--------* wWAs = 7.57 -- LV myocardial wall area, diastole  -  BW normalized
---------|-------|------*-- wWTd = 1.37 -- LV combined wall thickness, diastole - BW normalized
---------|-------|------*-- wWAd = 6.41 -- LV myocardial wall area, diastole  -  BW normalized
---------|-------|------*-- wWTs = 1.87 -- LV combined wall thickness, systole -  BW normalized
---------|-------|-----*--- wIVSd = 0.75 -- Interventricular septum thickness, diastole - BW normalized
---------|-------|----*---- wIVSs = 0.98 -- Interventricular septum thickness, systole - BW normalized
---------|-------|----*---- wLVODs = 2.96 -- LV outer dimension, systole -  BW normalized
---------|-------|---*----- wLVWd = 0.62 -- LV wall thickness, diastole - BW normalized
---------|-------|--*------ wLVWs = 0.90 -- LV wall thickness, systole  - BW normalized
---------|-------|--*------ wLVODd = 3.02 -- LV outer dimension, diastole -  BW normalized
---------|-------|*-------- wLA = 1.25 -- LA dimension - BW normalized
---------|---*---|--------- wLVIDd = 1.65 -- LV internal dimension, diastole - BW normalized
---------|---*---|--------- wDA = 1.53 -- LV internal cross sectional area change  -  BW normalized
---------|---*---|--------- wLVIDs = 1.08 -- LV internal dimension, systole  - BW normalized
 wAo = 1.10 -- Aortic dimension - BW normalized

ECHOCARDIOGRAPHY (2D)

Left atrial size was normal.  The left ventricular internal diastolic diameter was normal.The left ventricular internal systolic diameter was normal.  Left ventricular systolic function ( fractional shortening, end-systolic dimension) was normal.  Left ventricular "relative wall thickness" (FWTd, FWAd, RWTd) was moderately increased giving the appearance of hypertrophy.  Overall (combined free wall and septem), left ventricular wall thickness was marked-extremely increased.  The interventricular septum ( diastole) was markedly increased and the left ventricular "free" wall was moderate-markedly increased in thickness.  An index of LV hypertrophy (wWAd) was marked-extremely increased,  indicating true hypertrophy ( primary  differentials LV outflow obstruction, HCM,  systemic hypertension, hyperthyroidism).  An index of LV stroke volume was normal. 

While significant left ventricular hypertrophy is still present, there has been marked improvement in hypertrophy and wall thickness indices since the previous examination in October.  There is still a single false chordae tendenae extending from a papillary muscle to the interventricular septum.  Previously noted extraneous papillary muscles persist and there is increased echogenicity of the left ventricular endocardium.


---------|----*--|--------- wSAxLAA = 2.73 -- Left Atrial Area SAx - BW normalized
 SAxLAA  (cm2) = 6.79 -- Left Atrial Area -  RPS short axis (cm)

 

 

 

 

DOPPLER ECHOCARDIOGRAPHY

Aortic ejection velocity was normal.  The pressure gradient for the left ventricular outflow tract was at the upper limit of normal (equivocally increased) (15 - 20 mmHg gradient).  There is no further evidence of stenosis.
---------|------*|--------- MA_vp (m/sec) = 0.752 -- Mitral A peak velocity (m/sec)
---------|-*-----|--------- MEA_R = 1.016 -- Mitral E/A ratio
---------|-----*-|--------- A_vmx  (m/sec) = 2.0 -- Aortic velocity max (m/sec)
---------|---*---|--------- ME_vp (m/sec) = 0.764 -- Mitral E peak velocity (m/sec)
 A_ppt (mmHg) = 15.605 -- Aortic peak gradient (mmHg)

TISSUE DOPPLER

ME' (cm/sec) = 0.124 -- Mitral E' (cm/sec)

 

 

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