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Case 23
Follow-Up
Clinical Diagnosis
 | Severe tricuspid valve dysplasia |
Comments
| Radiographs: Severe right heart enlargement (right atrial
enlargement).
ECG: Heart rate irregular and ranged from 64-210 bpm, with a mean of 130 bpm. Coarse atrial
fibrillation. MEA +70 There are splintered QRS complexes (RSr') characteristic of tricuspid valve
dysplasia. Prominent R waves on V1 right chest lead, deep S waves in V4 left chest lead suggesting
right ventricular hypertrophy. |
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Echocardiogram: Due to the severe derangement in the cardiac size, M-mode measurements of the
left ventricle were not obtained. There was severe right atrial enlargement. The tricuspid valve is
severely dysplastic, with abnormal papillary muscle attachments to the tricuspid valve cusps. The
abnormal papillary muscles are severely tethering the tricuspid valves, causing a large gap in valvular
coaptation during systole. There is severe tricuspid regurgitation of normal velocity 2.8 m/s. |
| Conclusion: Max has severe tricuspid valve dysplasia and early right heart failure. This is a heritable,
congenital disease that is most commonly seen in Labrador retrievers. therapy is aimed at reducing
heart failure, and only definitive treatment is a tricuspid valve replacement. There is such severe
right atrial enlargement that even valve replacement might not be very effective. The prognosis is
guarded. |
Discharge Summary
| Max was seen at the VMTH to evaluate an arrhythmia and cardiomegaly found by the
referring DVM. Max has no clinical signs except a dry nonproductive cough that started about 2 weeks ago. On physical
exam a V/VI systolic murmur was noted over the right side of his chest and the heart rhythm was very
erratic. He has weak femoral pulses with pulse deficits. The jugular veins are distended. He also
had moderate hepatomegaly with no ascites. Radiographs revealed severe right atrial enlargement.
The ECG showed evidence of atrial fibrillation and were suggestive of tricuspid valve dysplasia
(splintered QRS complexes). The echocardiogram revealed tricuspid valve dysplasia with severe
tricuspid regurgitation and right atrial enlargement. Max was diagnosed with right heart failure. His
prognosis is guarded. Therapy was aimed at ameliorating the signs of right heart failure and included
the following: Lasix 50mg orally BID, digoxin 0.25mg orally BID, lisinopril 20mg orally SID.
Max will return in 7-10 days to check blood levels of digoxin and then again in 6 months for a
recheck. |
One Week Later
Pertinent History
| Max was diagnosed with severe tricuspid valve dysplasia on 11/3/99. He had a V/VI systolic
murmur over the right heart base with an erratic rhythm that was diagnosed as Atrial Fibrillation.
Echo showed severe right atrial enlargement , with severely dysplastic tricuspid valve and
abnormal papillary muscle attachment. At that time he was placed on Lasix 50 mg orally BID,
digoxin 0.25 mg BID, lisinopril 20 mg PO BID. Today Max presents for 3-4 days of anorexia and lethargy. |
Physical Examination
| Gen: BAR marginal dehydration |
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Integ : Good coat, salivary staining on hind paws. |
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MS: 4/9 |
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CV: IV/VI right sided murmur loudest at the apex, irregularly irregular rhythm (atrial fibrillation),
MM= pink, CRT< 2 sec, pulses of variable intensities but strong |
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RR= 78 (but panting), Clear lung fields. |
| Lymph nodes: WNL |
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GI: Hepatomegaly, gut loops smooth. |
Problems
| Tricuspid Dysplasia |
| Atrial Fibrillation |
| Anorexia |
Discharge Summary
| Max was diagnosed with severe tricuspid dysplasia and atrial fibrillation one
week ago. He was sent home on digoxin 0.25 mg BID, lisinopril 20 mg SID, and Lasix 50 mg BID. Today he presents
having been anorectic since the digoxin was started. We drew blood for a kidney panel and
digoxin level and sent him home with instructions to discontinue the digoxin until further notice. Digoxin
toxicity often results in GI side effects such as anorexia, vomiting and diarrhea. Results of digoxin
levels were 2.5 ng/ml - above our therapeutic range of 0.5 - 2.0 ng/ml. The
owner was instructed to stop giving digoxin for 2 days; then give 0.125 mg PO
BID. |
| Renal profile revealed normal BUN and creatinine; slight decrease in electrolytes most likely due to diuretic and anorexia. |
Five months later
| Max is still doing well. He remains on the same medications he was on
previously. He is active but tires easily when exercised and he remains a
finicky eater but otherwise is a happy boy.:) |
Two years later
| In a telephone conversation with Max's owner, he
says that Max is still doing wonderfully. He is currently on 50 mg Lasix BID,
15 mg enalapril BID, and digoxin. Max is retired from the narcotics squad and
living the good life. The only thing that Max's owner notices is that after a
two mile walk, Max starts slowing down a bit. Not bad for a big-hearted dog! |
Three years later
| Max was euthanized due to severe right heart
failure. He became emaciated, weak, and wouldn't eat. Max's owners currently
have a new 5-month-old Labrador puppy. Although no dog can ever replace Max,
the new puppy helps fill some of the void. |
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