Case Studies In Small Animal

Cardiovascular Medicine

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Case 39

At Time of Discharge

Discharge Summary

bulletSarah, a 5 year old female spayed Labrador Retriever, was presented to the UC Davis VMTH Cardiology Service for further evaluation and possible treatment of congenital tricuspid valve dysplasia with severe tricuspid valve stenosis. She has no history of heart disease prior to 6 months ago. She first presented to her rDVM in 6 months ago for weakness and walking strangely and 4 months ago for collapsing episodes which we suspect to have been syncopal episodes. After she was spayed on 3 months ago, the owners began to notice progressive abdominal distension and coughing.
bulletSarah's rDVM recommended a referral to a cardiologist. Subsequently, a veterinary cardiologist in the San Francisco Bay area performed an echocardiogram and diagnosed tricuspid valve dysplasia with severe tricuspid stenosis. She was prescribed 80mg furosemide BID and 15mg benazepril once daily. Sarah's owners report that her abdominal distension has gotten progressively worse and that she has also had a progressive reduction in activity level and appetite. Furosemide has been increased to 80mg TID but no other treatments have been performed.
bulletOn physical exam, Sarah was weak and lethargic, 5-8% dehydrated, and had a distended abdomen with a fluid wave. Her extremities were cold, her pulses weak, her CRT was 2.5 sec, and her mucous membranes were pale. Cardiovascular exam: Muffled heart sounds, difficult to auscult, particularly over right hemithorax. Soft diastolic murmur possibly ausculted over left hemithorax. No systolic murmur ausculted. Extra heart sound ausculted during early diastole. Pulses were weak and symmetric. No obvious jugular pulsation, but very fat neck with skin folds.
bulletWe performed an abdominocentesis as our first diagnostic procedure, after which she became much brighter with improved signs of increased cardiac output: her pulses were strong, and her CRT was approximately 1.5 sec. Approximately 4.5 L of transudate like fluid were removed.
bulletHer weight decreased by approximately 4 kg.
bulletA recheck echocardiogram was next performed.
bulletObjective measurements: Left ventricular measurements were not repeated.  
bulletTricuspid regurgitant jet velocity approximately 2.5m/s, PG 25mmHg
bulletTricuspid inflow profile: Decreased E wave height as compared with A wave, with approximate peak velocity 1.8m/s. No EF slope. The A wave maximum velocity was markedly increased. Maximum TV inflow velocity 3.27m/s, max PG 42mmHg, mean PG 17.5mmHg as assessed by VTI via spectral PW Doppler.
bulletSubjective findings: The left atrium and left ventricle appear normal to volume underloaded in size. LV contractions appear adequate. The mitral and aortic valves are unremarkable. There is septal flattening noted only during diastole. The right atrium is severely enlarged with a prominent right auricle. The right ventricle appears small and volume underloaded; it is difficult to assess due to severity of RA enlargement. The pulmonic valve is unremarkable with trivial pulmonic insufficiency. The RVOT appears unremarkable. The tricuspid valve apparatus is very abnormal. The valve annulus appears distally displaced into the right ventricle. The valve leaflets appear relatively immobile, with minimal excursions during diastole. There are abnormal chordal attachments into the RV, directly onto RV walls and to papillary muscles. There is trivial to mild tricuspid regurgitation, and evidence of severe tricuspid valve stenosis based on color flow and PW Doppler inflow measurements. On PW inflow measurements, there is a increased E wave max velocity, no EF slope, and severely increased A wave maximum velocity, and increased mean inflow velocity as assessed by VTI of PW spectral inflow profile.
bulletA persistent left cranial vena cava (PLCVC) is visualized on 2D echo.
bulletContrast echocardiogram (bubblegram): This was performed to rule out a right-to-left shunt and to confirm the diagnosis of persistent left cranial vena cava. It was crucial to determine whether PLCVC was complete, or if a right CVC was also present for the anticipated cardiac catheterization procedure. Results showed that there was a partial PLCVC, with presence of a right cranial vena cava, both with entrance into the right atrium.
bulletThoracic radiographs: Severe right atrial/right auricular enlargement was present. The caudal vena cava was markedly distended. Pulmonary vasculature is normal to mildly diminished in size. No evidence of pulmonary infiltrates or pleural effusion.
bulletECG: Sinus tachycardia; P pulmonale present; splintered QRS complexes noted only on the V4 lead.
bulletCytology performed on ears and foot lesion: revealed Malassezia otitis externa, Malassezia pododermatitis, and deep pyoderma.
bulletAssessment: Sarah was diagnosed with congenital tricuspid valve dysplasia with severe tricuspid stenosis, trivial to mild tricuspid regurgitation, and right congestive heart failure. Additionally, she shows clinical signs consistent with low output. Discussed these findings and diagnosis with owners. Discussed options for treatment including medical management and interventional treatment via balloon valvuloplasty of the tricuspid valve.
bulletSarah was anesthetized and prepped for balloon valvuloplasty of tricuspid valve stenosis. A TEE was performed to better elucidate the anatomy of the tricuspid valve stenosis, however accurate visualization of the tricuspid valve was difficult.
bulletA cut-down to the right external jugular vein was performed, and a venotomy was then made. A balloon wedge catheter was introduced and attempted to be placed across the tricuspid valve and into the MPA. This was impossible. A second catheter was advanced across the tricuspid valve, allowing introduction of a J tip exchange wire to be passed through her tricuspid valve and out her right ventricular outflow tract. A balloon catheter was then introduced but could not be passed across the tricuspid valve. Multiple attempts were made to pass a catheter across her tricuspid valve. Guide wires were successfully introduced across her tricuspid valve, into her RV apex, and into her MPA, but a 25mm balloon catheter, and then a 22 mm balloon catheter, were both tried, and it was only possible to inflate the balloons in her right atrium, but seemingly not across the tricuspid valve. However, multiple manipulations of catheters and the guidewires used were performed across the tricuspid valve.
bulletSeveral angiograms were performed which revealed the level and location of the tricuspid valve stenosis.
bulletPressure waveforms of the MPA, RV and RA revealed normal pressure waveforms in the MPA and RV, and an elevated mean RA pressure of approximately 15-20mm Hg, with a markedly elevated A wave on all pressure tracings, both before and after all balloon inflations and manipulations. A wave maximum pressure measurement was approximately 25mmHg. No significant changes in RA pressure waveform were noted post procedure.
bulletAfter approximately four hours of attempting interventional treatment, the procedure was aborted. The final angiogram showed no evidence of significant tricuspid regurgitation, or change in the appearance of the angiogram.
bulletThe right external jugular was ligated with 3-0 silk. Layered closure with 3-0 PDS was performed. Skin closure with staples was performed.
bulletThe patient recovered unremarkably from anesthesia and was recovered in PAR and in the wards. At the end of the procedure day, moderate ascites was present.
bulletThe following day: Although initially lethargic on PE in the morning, by the afternoon Sarah was bright, alert and ambulatory and there were only small pockets of ascites present in her abdomen on an informal abdominal ultrasound. A repeat abdominocentesis was not performed as it was not indicated. Physical exam otherwise was essentially static with regular rhythm and similar heart sounds.
bulletRecheck echocardiogram: The left heart remains unremarkable. The right atrial size is essentially static. There continues to be mild tricuspid valve regurgitation which has not changed significantly. Subjectively, there is improved flow across the tricuspid valve during systole on color flow. There seems to be a mild improvement in inflow velocities and spectral inflow profile (decreased height of A wave, decreased mean and max PG). EF slope remains flattened. HR is reduced.
bulletObjective measurements: TR jet velocity and PG static. TV inflow pattern: Reduced maximum velocity of both E wave and A wave. EF slope remains very flattened. Based on VTI measurements: Max inflow PG 21 mmHg; avg. inflow PG 8 mmHg
bulletAssessment: Tricuspid Valve Dysplasia (TVD) with severe tricuspid valve stenosis. Partial success in opening up valvular stenosis likely secondary to manipulations of guide wires and catheters across the stenosis, as balloon dilation itself did not appear to be successful. Mild to moderate reduction in mean and maximum tricuspid valve diastolic inflow PG. This result will hopefully lead to at least short term palliation of patient's clinical signs of right heart failure and syncope, however, it is possible that long term the patient will begin to experience these problems again if the tricuspid valve fibroses back down to a stenotic orifice. Sarah was discharged on 2 days later with instructions for monitoring her incision site several times daily for signs of infection and staple removal in 10-14 days. She was prescribed a decreased dose of furosemide 60mg BID, benazepril 15mg once daily, and pimobendan 10mg BID. It is expected that this reduced dose of furosemide will improve her overall hydration level and reduce any symptoms of low output, however, she may require abdominocentesis in the future.
bulletTo treat her dermatologic issues, she was also prescribed fluconazole 150mg PO once daily for 4 weeks for otitis, cephalexin 1000mg PO once daily for 8 weeks for treatment of pyoderma associated with acral lick granuloma, and Epi-Otic ear flush daily long term. Instructions were given to schedule a recheck appointment in 4-6 weeks with the Cardiology Service. Ideally, she should also be followed long term by a dermatologist for her chronic recurrent otitis externa, and acral lick granuloma with suspect pyoderma associated.
bulletOwners to call with any questions or concerns prior to recheck with Dr. Paling. They understand that Sarah may decline with time, and a repeat intervention or surgery may be indicated.

 

Four Weeks Later

Discharge Summary

bulletSarah is a 5 year old, female spayed Labrador Retriever who was presented to the VMTH Cardiology Service for recheck evaluation of recently diagnosed tricuspid valve dysplasia with severe tricuspid stenosis, trivial tricuspid regurgitation, and right heart failure. She had a balloon valvuloplasty performed 4 weeks ago which was partially successful in releasing the stenosis and she has been doing well at home since that time per owner.
bulletOn physical examination, Sarah was bright, alert, responsive, and hydrated. Significant improvement in attitude and appearance as compared to initial presentation.
bulletCardiovascular examination: HR-100-110bpm, regular rhythm with femoral pulses strong, synchronous, and symmetrical. Soft systolic murmur ausculted over the left hemithorax, difficult to auscult over right hemithorax. No arrhythmias, but an extra heart sound (S4) was ausculted. Bronchovesicular sounds ausculted in all fields. No jugular venous distention noted. No subcutaneous edema. No ascites.
bulletRecheck echocardiogram: Objective measurements: Tricuspid inflow velocities: Peak E wave velocity 1.8 m/s, PG 13 mmHg, Peak A wave velocity 2.6 m/s, PG 29 mmHg. Tricuspid inflow velocity time integral: Vmax 2.4 m/s, Vmean 1.6 m/s, Max PG 23 mmHg, Mean PG 11 mmHg, VTI 75.1 cm, TV E/A ratio 0.7
bulletSubjective findings: The left heart continues to be unremarkable with normal chamber sizes and adequate LV contractions. The left heart appears to be adequately volume loaded today.
bulletThe right atrium is severely enlarged, this is essentially static. The tricuspid valve appears essentially the same with reduced diastolic excursions. There still appears to be improved amount of diastolic flow across the valve, although the flow remains turbulent in appearance; the jet appears to be larger. Trivial tricuspid regurgitation. Distal displacement of the tricuspid valve apparatus into the right ventricle. No other notable changes.
bulletRecheck brief abdominal ultrasound: No evidence of ascites today. Moderate hepatomegaly, no obvious hepatic venous distention.
bulletAssessment: Sarah is doing well and clinically stable to improved today. She shows no clinical evidence of residual or recurrent right sided congestive heart failure. Her recheck echocardiogram shows that there continues to be improved, but turbulent, flow across the tricuspid stenosis. Inflow measurements are essentially static to those noted after procedure (mild increase in mean PG).
bulletIt is likely that Sarah will continue to do well for some time, but there is a possibility that Sarah will need a repeat attempt at balloon valvuloplasty, or else attempt at surgical palliation of the tricuspid stenosis in the future to prevent recurrent right heart failure and/or syncope.
bulletThe plan is to continue medications for now, but we will likely try to wean Sarah from her diuretic.

 

Eight Months Later

Discharge Summary

bulletSarah, a 5 year old FS Labrador, was presented to the VMTH Cardiology Service for evaluation of tricuspid dysplasia causing tricuspid stenosis. The owners' were concerned with potential seizure episodes that began two months ago. Sarah has episodes of disorientation, glazed look, ataxia, trembling/shaking, urination/defecation/vomiting, and not being responsive for about 30-60 minutes duration after an event. There are no points in time when Sarah was unconscious ("passed out"). These occurred again 3 days ago and then once again yesterday. The episodes have occurred in the middle of the night, early in the morning, and once after a walk. The owner has also noticed increased panting since the first episode.
bulletOn physical exam, she was bright and responsive. A grade II/VI right diastolic murmur could be heard. An ECG was performed and showed a regular rhythm with tall P waves and HR of 101.
bulletECHOCARDIOGRAM:
bulletSubjective findings: Moderate right atrial enlargement, tricuspid valve stenosis with ventral displacement into the right ventricle. Adequate contractility.
bulletObjective findings: Mean tricuspid inflow pressure gradient of 11mmHg (avg 3 beats).
bulletBrief examination reveals no obvious ascites or hepatic venous congestion is appreciated.
bulletHer cardiac findings were very similar to her exam in March. We recommend discontinuing the Pimobendan at this time and monitoring how she does. We feel her seizure episodes are not cardiogenic and recommend videotaping the episode and making an appointment to see the Neurology Service.

Mark D. Kittleson, D.V.M., Ph.D. All rights reserved.