You are presented with a cat which has pulmonary edema, a gallop heart rhythm, a heart murmur and weak femoral arterial pulses. The radiographs reveal generalized cardiomegaly with pulmonary edema. The electrocardiogram reveals a normal sinus rhythm and left ventricular enlargement.
Question: Does this cat have cardiomyopathy and if so what type is it?
Routine two-dimensional echocardiography reveals a heart typical of left ventricular concentric hypertrophy; i.e., the cavity of the left ventricle is reduced relative to the increased thickness of the interventricular septum and the left ventricular free wall. The left atrium is increased in size. The right side of the heart appears normal.
The M-mode Echocardiogram is used to determine the thickness of the interventricular septum, the left ventricular internal dimension, and the left ventricular free wall in both diastole and systole.
There is no real value in performing a Doppler Echocardiographic study in this individual. A Doppler examination however may show evidence of reduced left ventricular compliance (diastolic disease) and / or increased velocity of blood flow across the left ventricular outflow tract.
Diagnosis: This is a typical case of Hypertrophic Cardiomyopathy in the cat. This may be due to thyrotoxicosis or it may be idiopathic.
Note that Dilated Cardiomyopathy would have presented with the following Two-dimensional and M-mode Echocardiographic findings. The left ventricular lumen would be increased in size and the left atrium would also be increased in internal dimension. The M-mode examination would have revealed a normal thickness to the interventricular septum and left ventricular free wall, and an increase in the left ventricular internal dimension in diastole (>18mm) and a relative reduction in the left ventricular internal dimension in systole. Thus the index of left ventricular contractility, fractional shortening
[(LVID-D - LVID-S)/LVID-D], would be reduced (normal = 25-45%).
A six year old German Shepherd presents to you for a sudden onset of marked lethargy and exercise intolerance. On physical examination the heart sounds are muffled and the femoral arterial pulses are very weak. Thoracic radiographs reveal marked cardiomegaly and no pleural effusion. There is no evidence for pulmonary edema. The EKG reveals low amplitude QRS complexes.
Question: Does the very enlarged heart represent heart failure, if so what is the cause?
The Two-dimensional Echocardiogram reveals a marked pericardial effusion. A thorough examination of the region of the right atrium indicates a mass attached to the outside wall. Although M-mode Echocardiography is ideal to assess the contractility of the left ventricle, in the presence of the pericardial effusion such assessments are erroneous.
Some ultrasonographs enable the technician to perform ultrasound assisted biopsies. Thus a sample of the effusion can be obtained for analysis and culture with the assistance of ultrasound to guide the placement of the biopsy needle.
Doppler Echocardiography has no real value in this type of case.
A 12 year old dog presents to you for a 6 month history of a chronic cough. The cough is exacerbated by excitement, exercise and stress. The cough has progressed markedly over the last month. On physical examination a thrill is palpated over the left chest and a marked systolic heart murmur is noted with a point of maximal intensity over the left cardiac apex. On thoracic radiography the heart is enlarged, the left atrium is enlarged, there is a prominent interstitial pattern in the lungs which is mainly a peribronchial pattern. The EKG reveals left ventricular enlargement and left atrial enlargement. There is no evidence of a dysrhythmia.
Question: Is the cough due to pulmonary edema a result of heart failure?
The Two-dimensional Echocardiogram reveals an enlarged left ventricular and left atrial cavity. Subjectively, the left ventricle appears to be strong (adequate contractility). The M-mode Echocardiogram reveals increased left ventricular internal dimensions in diastole and in systole, and normal contractility (fractional shortening = 47%).
F. Shortening 47%
Left Atrial-S 22mm
Given that the index of contractility is normal, can we suggest that the heart is strong enough and thus not responsible for the cough? In the face of mitral valve insufficiency, we anticipate that it is easier for the left ventricle to contract. Thus the adequate contractility calculated may merely reflect that the ventricle may be ejecting blood in the wrong direction. It has been suggested that if the LVID-S is normal then the heart is probably normal in strength in spite of the mitral valve insufficiency.
Thus as the LVID-S is normal, we believe that the left ventricle and thus the heart is not responsible for the cough. Thus therapy for pulmonary edema of cardiogenic causes is not necessary at this time.
Doppler Echocardiography can be used to demonstrate the existence of mitral valve insufficiency. Although this confirms the existence of MI, it adds little new knowledge to this case. The Doppler examination may provide evidence of the amount of forward flow into the aorta and the amount of backward flow into the left atrium.
A six year old Doberman Pinscher presents to you for an acute onset of dyspnea and wheeze. On physical examination the lung sounds are harsh, there is a soft left apical systolic heart murmur, and there are several premature beats noted in the cardiac rhythm. Thoracic radiographs indicate mild left ventricular enlargement, left atrial enlargement, and pulmonary venous congestion and edema. The EKG indicates the infrequent uniform ventricular premature beat, otherwise the EKG is normal.
Question: Does the dog have Dilated Cardiomyopathy?
The Two-dimensional Echocardiogram reveals left ventricular enlargement and left atrial enlargement. The contractility appears subjectively to be reduced. The M-mode Echocardiogram reveals an increase in the left ventricular internal dimension in diastole and systole and an increase in the left atrial internal dimension in systole.
F. Shortening 11.5%
For the Doberman the LVID-D should not be more than 40mm. Thus we have documented the presence of a global reduction in contractility and marked left ventricular enlargement. This is typical of Dilated Cardiomyopathy.
Doppler Echocardiography would reveal mitral valvular insufficiency and reduced stroke volume. Although this information is useful, we were able to deduce these findings without the application of Doppler Echocardiography.
A 3 month old Sheltie female pup presents for vaccination. The physical examination reveals a continuous heart murmur. This finding alone is usually sufficient to indicate the existence of Patent Ductus Arteriosus. The EKG reveals marked left ventricular and left atrial enlargement. Thoracic radiographs reveal left ventricular and left atrial enlargement and pulmonary venous congestion and pulmonary edema.
Question: Is there any use for Echocardiography in this disorder?
Echocardiography is useful to:
The Two-dimensional examination reveals enlargement of the left ventricle and left atrium. It is still uncertain as to how frequently the ductus arteriosus itself can be visualized. The M-mode Echocardiographic study does not increase our understanding of this disorder.
The Doppler Echocardiographic study reveals the presence of turbulence in the main pulmonary artery which occurs in both systole and diastole. This picture of turbulence in the main pulmonary artery is similar to that seen with pulmonic stenosis, however with pulmonic stenosis this pattern of turbulence is noted only in systole. Furthermore, the Doppler Echocardiographic examination is ideal to identify the co-existence of other congenital cardiac disorders.
A 4 month old male Newfoundland presents to you for vaccination. A left basilar systolic heart murmur is noted that radiates well to the right chest. Thoracic radiographs reveal a normal cardiac silhouette and no evidence of pulmonary vascular or interstitial disease. The EKG is normal.
Echocardiography is of outstanding value to confirm a presumptive diagnosis of aortic stenosis or subaortic stenosis. In this disorder, short of cardiac catheterization, there is no other method available to confirm the existence of aortic stenosis.
Although routine Two-dimensional Echocardiography may give us clues to the existence of aortic stenosis, in many cases this test is inconclusive. In severe cases of aortic stenosis, the Two-dimensional exam may reveal left ventricular concentric hypertrophy and a discrete subvalvular lesion, in the case of subaortic stenosis. The M-mode Echocardiographic examination may reveal a clue to the presence of co-existent aortic valve insufficiency (diastolic fluttering of the anterior leaflet of the mitral valve) premature closure of one cusp of the aortic valve. As well this modality should indicate evidence of left ventricular concentric hypertrophy.
The Doppler Echocardiographic study yields data which usually definitively establishes the diagnosis of aortic stenosis and provides evidence of the severity of the disorder. Doppler Echocardiography determines the velocity of blood flow as it exits the left ventricle. The normal maximal velocity of blood flow exiting the left ventricle is approximately 1.5 meters per second. Thus velocities detected in excess of 1.5 m/s suggest stenosis of the column of blood flow (especially velocities in excess of 2.0 m/s). In addition, we have noted that aortic valve insufficiency occurs in a large percentage of cases of subaortic stenosis. It appears that this aortic valve insufficiency does not significantly hemodynamically embarrass the performance of left ventricle, however it does frequently serve as a useful marker to the presence of concurrent subaortic stenosis. As the subaortic stenosis progresses the maximal velocity of blood flow across the stenotic region increases. Severe stenosis is characterized by a velocity of blood flow of 5 m/s or greater.
In this dog the Doppler study revealed a velocity of blood flow exiting the left ventricle of 3.5 m/s and the presence of aortic valve insufficiency.
A 3 month old Samoyed presents to you for vaccination. On physical examination a left basilar systolic heart murmur is detected. Thoracic radiographs appear normal. The EKG also is normal. Once again Echocardiography is ideal to confirm the diagnosis of this congenital cardiac disorder. As for aortic stenosis, Doppler Echocardiography is the specific mode of echocardiography which offers the most information to establish the diagnosis of pulmonic stenosis and address the severity of the disorder.
Routine Two-dimensional Echocardiography nevertheless provides much insight into the disorder. As the severity of the pulmonic stenosis increases, one will observe an increase in the thickness of the interventricular septum and right ventricular free wall. The moderator band of the right ventricle also increases in size. The region of the pulmonic valve is noted to be narrowed and the motion of the pulmonic valve is seen to be restricted (reduced amplitude of excursion). The main pulmonary artery is usually noted to be enlarged. On the M-mode examination the measured thickness of the interventricular septum is increased as well as that of the right ventricular free wall. The motion of the interventricular septum is noted to be abnormal demonstrating a flat motion in systole.
The Doppler Echocardiographic examination reveals an accelerated velocity of blood flow across the pulmonic valve in systole. The normal maximal antegrade velocity of blood flow across the pulmonic valve should be no more than 1.2 meters per second. Thus peak velocities of blood flow detected in excess of 1.2 m/s (especially velocities in excess of 2.0 m/s) across the pulmonic orifice in systole suggest pulmonic stenosis. As the severity of the stenosis increases the measured maximal velocity of blood flow detected increases. Velocities in excess of 5 m/s indicate a severe degree of stenosis.
The Doppler study in this dog revealed a velocity of blood flow across the pulmonic valve of 2.5 m/s and pulmonic valve insufficiency.
Routine Two-dimensional Echocardiography and Doppler echocardiography are useful to detect intracardiac shunts and dysplasia of the mitral and tricuspid valves.