Follow-Up

Case Studies In Small Animal

Cardiovascular Medicine

Case 11

Case Discussion

The heart was markedly enlarged on the thoracic radiographs and the left atrium was noticeably larger than all other chambers. On his ECG, he had occasional premature complexes (fourth and 25th complexes). These QRS complexes were abnormally oriented, wider than the sinus QRS complexes, and had abnormal T waves following them that were opposite in polarity to the QRS complexes. These features are consistent with premature ventricular complexes (PVCs). Note that each of these had a P wave in front which may make one tend to think they are supraventricular in origin. Note also, however, that the PR interval is very short, especially when compared to the normal PR intervals in other complexes. These leads one to surmise that the P waves and the QRS complexes are not associated. Rather, an ectopic focus in a ventricle depolarizes before the sinus depolarization can make it through the AV node to the ventricles. The premature complexes come in 7 mm (7/25th of a second or 0.28 seconds) after the sinus QRS complexes and so are depolarizing at a rate of 215 beats/minute (60 beats/minute divided by 0.28 seconds per beat).

On the echocardiogram, Joey had severe mitral regurgitation due to myxomatous degeneration of his mitral valve leaflets and chordae tendineae. The latter resulted in rupture of at least one minor chord if not more. The ruptured chord was evident on the two-dimensional echocardiograms (the arrow). The force of the jet against the interatrial septum and/or the high left atrial pressure resulted in an endocardial tear and perforation of the interatrial septum. This resulted in an acquired atrial septal defect. Joey was lucky. A perforation in any other part of its septum would have resulted in hemorrhage into the pericardial sac and acute cardiac tamponade. This most commonly results in acute death. The picture below is from another dog with an endocardial tear (thick vertical arrow). The tear in this dog did not perforate the atrial wall. However, the primary chord to the septal leaflet (thin horizontal arrow) in this dog ruptured resulting in acute death.

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Joey most likely went into right heart failure because of the acquired atrial septal defect coupled with the existing tricuspid regurgitation. The increase in right heart volume brought about by the left-to-right shunting of blood at the atrial level would increase right atrial and right ventricular diastolic pressures. This would increase systemic venous and capillary pressures resulting in transudation of fluid, in this case, into the abdomen (i.e., ascites).

The continuous wave Doppler velocity tracing of the systolic jet in the left atrium showed that the pressure gradient across the mitral valve was 115 mm Hg. The dog's systolic systemic arterial blood pressure was approximately 170 mm Hg. What is the systolic pressure in this dog's left atrium using this jet velocity? To determine this subtract 115 mm Hg from 170 mm Hg to get 65 mm Hg. This is a tremendous increase in the systolic left atrial pressure. This tremendous increase may explain why the left atrial wall tore and then ruptured.

The continuous wave Doppler beam of the blood flow jet that was flowing from the left atrium to the right atrium showed a pressure gradient across the interatrial septum of 47 mm Hg. Since this dog was in right heart failure (i.e., has ascites), its right atrial pressure must have been between 10 and 15 mm Hg. If we assume that it is 13 mm Hg, then this dogs calculated systolic left atrial pressure using this jet velocity (note that it is slightly different from what you calculated above) must have been 60 mmHg.

This dog also had a cardiac arrhythmia (fifth beat on the ECG trace of the spectral Doppler recording). It was a premature ventricular complex (PVC).

Treatment

Joey was sent home on furosemide 50mg 1 tab TID and enalapril 10mg 1/2 tab SID. This level of furosemide should help to decrease the ascites and alleviate the volume overload this dog has. The enalapril should also help to relieve the volume overload.

Discharge Instructions

	Joey has advanced degeneration of the mitral and tricuspid valves. This causes blood to flow backward in the heart. Fluid then builds up in the lungs (pulmonary edema) and the abdomen (ascites). Joey also has a hole in one of the walls between two of his heart chambers. The hole in the heart is likely to be an acquired atrial septal defect, due to a tear in the wall.
	Treatment to remove the fluid buildup will require moderately high doses of diuretics. We have prescribed Lasix 50mg, one tablet three times daily.
	Also the enalapril can be given at 5 mg (1/2 of a 10 mg tablet) once daily.
	A blood sample has been taken to check his kidney function. We will call you with the results tomorrow.
	5.We would like to see him back next week. He may be started on amlodipine at this time, a drug to lower his blood pressure and improve his heart function.

Follow-up

One week later

Joey was seen again one week later. He was feeling better. He still had some labored breathing but seemed to be a little more comfortable. He was eating and drinking well and taking his medications. There was no coughing, wheezing or vomiting. He had some diarrhea yesterday. No collapsing episodes. His chemistry panel was normal.

Two weeks later

One week after the last visit Joey was seen again and seemed to be losing more weight. Also, he was behaving like he was having trouble seeing at night. His appetite was good, though he is a picky eater. Yesterday he seemed very lethargic, but he was outside in the heat all day. He had dark, runny diarrhea yesterday and urinated in his bed 2 days ago. He was still taking prescribed dosages of medications. He had a painful distended abdomen. A fluid wave was produced. He had an enlarged liver. On rectal
exam, his prostate was smooth and not enlarged. There was no blood seen in the feces.

Blood pressure: Prior to an amlodipine dose it was 150/92 with a pulse rate = 170 beats/minute. Two hrs after amlodipine (0.625 mg) the blood pressure decreased to 118/71. The dosage of amlodipine was sufficient to lower his blood pressure without becoming hypotensive. As a result Joey was maintained on amlodipine 1/4 tab (.625mg) BID in an attempt to reduce afterload and thus reduce regurgitant fraction. He was continued on his previous medications as well. Radiographs: There was a slight increase in the pulmonary infiltrates from the last radiographs that were taken. Approximately 1L of modified transudate was tapped from the abdomen.

Conclusion: Joey may need abdominocentesis in the future again. It is possible that the removal of the ascitic fluid will improve Joey's appetite. Joey will return for a recheck if his respiratory rate increases, if the ascites returns or he develops other problems such as lethargy, vomiting etc.