Case Studies In Small Animal
Subsequent Examinations (notes taken from the case record)
Two Days After Discharge
Freckles is looking clinically better today. A brief echo of his heart revealed
Five Days After Discharge
A brief echo showed persistent spontaneous contrast in the left atrium. PT is 13.4 s
which is still within the normal range, but is longer than when tested two days ago.
Ten Days After Discharge
ECHO: An echocardiogram of Freckles heart showed a very large clot in his left auricle.
There is also spontaneous contrast in his left atrium. Freckles PT is 98 seconds. This is
A right parasternal short-axis view of the aorta (AO) and left atrium (LA). There is a large thrombus (arrowheads) in the left auricle that has formed despite warfarin therapy and despite the fact that the prothrombin time in this cat was markedly prolonged.
Two and one-half Weeks After Discharge
PT: 11.6 sec (WNL).
Three and one-half Weeks After Discharge
This last week, Freckles has lost weight, seems lethargic and is not eating well. The owner believes this started with the start of aspirin therapy.
Echo: persistent spontaneous contrast and left atrial thrombus. Moderate pleural
Four and one-half Weeks After Discharge
This past week Freckles has been doing better, eating well and more active. He has shown more respiratory effort however.
Thoracocentesis: 220 mls chylous fluid removed.
Seven Weeks After Discharge
Freckles has HCM. He is on atenolol 6.25 mg BID, enalapril 1.25 mg PO SID, and Lasix
Echo: the left atrial thrombus is unchanged in size and is still attached to the wall,
however it appears to have some mobility.
Ten Weeks After Discharge
Freckles respiratory rate is increased again. The echocardiogram revealed that there was no thrombus present in the left atrium today. He has shown no signs of systemic thromboembolism. 140 mls of fluid was removed from the pleural space.
Eleven Weeks After Discharge
Freckles is currently on Lasix 18.75 mg PO BID, enalapril 1.25 mg PO SID, and atenolol BID. The owner feels that he is dehydrated lately and he has not eaten well or had his normal energy level in the last few days. She was advised yesterday to discontinue the Lasix until the recheck today. She did that and Freckles ate well today. No increased respiratory effort or rate noted.
HR 160, irregularly irregular, mm pale gray/pink, femoral pulses weak, approximately 8% dehydrated by skin turgor and mm moistness. Abdominal palpation WNL. Extremities slightly cool.
Echo: a new thrombus is visualized in the left atrium. Severe pleural effusion noted
and 175 mls chylous effusion removed.
Twelve Weeks After Discharge
Freckles has severe HCM with secondary pleural effusion. He is on Lasix 12.5 mg PO BID, atenolol 6.25 mg PO BID, and enalapril 1.25 mg PO SID. Last week he was dehydrated and hypokalemic. Lasix was discontinued for 2 days and reinstituted at 12.5 mg PO BID and potassium supplemented at 2 mEq BID. He was doing better but as of yesterday the owner feels he is not doing well and is having trouble breathing.
PE: Tachypneic with dull lung sounds ventrally. Depressed, cyanotic mucous membranes. Cachectic. Irregularly irregular HR 160 bpm. Poor femoral pulses.
220 mls chylous effusion removed from pleural space. Freckles appeared improved
Thirteen Weeks After Discharge
Freckles has severe HCM with secondary pleural effusion. He is here for a recheck of the pleural effusion. The Lasix dose was increased to 18.75 mg PO BID again at the last recheck. He has been doing well at home.
Lung sounds dull ventrally. Cat is eupneic. Cachexia. HR 160 irregularly irregular. Mm pale pink.
105 mls chylous effusion drained from the pleural space. The left atrial thrombus
remains large and mobile with significant slow spontaneous contrast.
Fourteen Weeks After Discharge
Freckles has HCM. He is on Lasix, enalapril and atenolol. He recently has had
Echo: The left atrial thrombus appears subjectively larger than last week with little area for flow around into the LV. A picture was not taken because Freckles seemed clinically fragile and the echocardiogram had to be done while he was standing. A large amount of pleural effusion is noted and 140 mls of chylous effusion was removed. Only a small amount remained.
Fifteen Weeks After Discharge
Freckles has HCM and is on atenolol, Lasix and enalapril. He has needed weekly
HR 150 bpm irregularly irregular. Mm pale pink, Dull lung sounds ventrally. Extremities
160 mls chylous effusion removed via thoracocentesis. LA thrombus unchanged.
Sixteen Weeks After Discharge
Phone Conversation: Freckles was doing well. The owner went to the store and when she came home he was dead, lying peacefully in the hallway (i.e., he died suddenly). The owner buried Freckles in the back yard.
Freckles lived for four months with severe cardiac disease and a large left atrial thrombus that came and went. No one expected him to live this long but he, his owner, and Dr. Adin hung in there. The results exceeded all expectations. His outcome, however, should in no way be used to predict the outcome of any other cat with the same disease processes. Many cats that present with a saddle thromboembolus die soon after or later of this complication, die from their heart disease, or are euthanized. Almost all cats that have a large left atrial thrombus do poorly and die of complications. Freckles was a "miracle" cat. One of those patients that defied the odds for much longer than expected.
©Mark D. Kittleson, D.V.M., Ph.D. All rights reserved.