Liz Bode
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Replying to Christina Frigast 01/01/2023 - 11:08
Happy New Year to both of you (and everyone else reading this post)
Brilliant!! Yes, this is a sinus tachycardia (which fits with CHF due to sympathetic drive maintaining cardiac output). There is P pulmonale as the P wave is taller than it should be, consistent with RA dilation. The QRS is splintered and this probably reduces the overall height of the R wave. The QRS is splintered like this as the electrical activity finds a different path to travel through the conduction system than normal (possibly due to ischaemia/ fibrosis etc). These findings are ‘commonly’ seen in dogs with tricuspid valve dysplasia. Here is the original report:
https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1939-1676.1997.tb00095.x
Liz 🙂Hi everyone,
Just a reminder about our Live Q and A session on 9th January at 8pm.
The zoom link can be found under the lesson for the week. The session will be recorded and uploaded to the website after editing (which can take a week or two to do). If you can’t come along but have questions about cases that you would like me to chat about then please feel free to send me those (Liz@vtx-cpd.com). If you’re there in person then bring along cases etc for us to chat about. I’ll also bring some things with me.
Hopefully see as many of you as possible next Monday 🙂
Liz
Hi Christina,
Interesting! My first thoughts (before reading your whole question) was this could have been an AIVR but not at a rate of 200bpm. In short, no I’ve not seen this following medetomidine. However, I have seen similar cases in dogs, the most recent was a Lab who was under GA and developed VT. I ran a troponin and this was very high (from memory >10) and I thought it had suffered some sort of ischaemic event under GA. Myocardial hypoxia (possibly from vasoconstriction effect of the medetomodine or reduced cardiac output) could be responsible for what you saw. In the case of my Lab – echo was normal but VT was still present on a Holter 24hours later. After discussion with the owner we didn’t treat and repeated the Holter two weeks later which was completely normal. I felt that this supported my thought of transient myocardial hypoxia (there was an issue on induction in this case though). Perhaps your dog just had mild/ more transient regional myocardial hypoxia than mine?
Liz
Hi Ursula,
I know we have chatted about this informally but thought I would answer your post too 🙂 In terms of if a cat comes to see me with an ATE I start clopidogrel at 75mg ONCE then 18.75mg/cat/day from then. I will use Fragmin (dalteparin) whilst in hospital too. The CURATIVE guidelines (2019) suggest clopidogrel and either dalteparin or a factor Xa inhibitor should be used in cats at risk of ATE but that there is no evidence to support this. So, perhaps there is some rationale to send cats home with both clopidogrel and factor Xa?
I’d be interested to hear others thoughts, especially those in ECC clinics who will see more of these cases than me.
Have a lovely Xmas.
LizHi all,
No takers yet for this case, perhaps I will bring this one to the live Q and A session? Or would you prefer me to write my thoughts on the first stage here? Happy either way.
The live Q and A session will be recorded for those who can’t attend 🙂
Liz
Replying to mike m. 10/12/2022 - 15:19
Hi Mike,
I think, if you can from an owner perspective, that this is always a good thing to do. I talk a bit more about it in the feline week, but if you have a breed that has a high chance of HCM such as a Ragdoll or Sphynx then an echo (or brief LA:Ao and HCM check) or NTproBNP would be a sensible plan. Echo would always be first choice but failing that the BNP should at least pick up more severely affected cases.
Liz
Hi Scott,
Yes, this paper is sometimes referred to for the management of pericardial effusions. I think it was the RVC if I remember correctly. To be honest I have never thought or needed to place a pericardial catheter in for a longer period of time than drainage takes. In my mind, if you drain them then only a handful will refill quickly and these tend to be the neoplasia cases. So given it is the minority of cases that refill quickly I think most PE cases don’t warrant the expense/ expertise/ nursing care that placing an in-dwelling catheter would need. Most of my PEs tend to go home after 24 hours. I guess you could consider an in-dwelling catheter in those cases that refill quickly whilst you are waiting for diagnostics to be returned.
Liz
Replying to Nicholas K. 16/11/2022 - 10:48
Hi Nick,
So sorry that this slipped form my radar too! In answer to your echo related questions:
For fractious cats I would use gabapentin initially – it takes the edge off them and has little effect on echo parameters so is fine to use. It will only allow you to echo those cats that are anxious and not the ones that are very aggressive – in my experience you still need something stronger for this. In cases where gaba is not enough I would use butorphanol and alfaxalone – IV if you can get access with gaba but if not IM – only issue is that IM does seem less reliable but it is only a small number of cats where you would need something other than IM butorphanol and alfaxalone.
Liz
Replying to Thaleia M. 27/11/2022 - 19:55
Hello Thaleia,
This is a good question. Cats are so tricky – we always joke that we should echo EVERY cat (or perform NTproBNP) as you never know which one has heart disease and which doesn’t. However, if you have no abnormalities on auscultation at all, and the cat is otherwise healthy, then I wouldn’t be inclined to do anything further. Then if things change later in the cats life you could always perform NT-proBNP at that point (or echo if you can).
Liz 🙂
Hi both,
Great to see you guys on here too 🙂 I hope you get something from it. Last year we had another ESAVS candidate and she really enjoyed it, so fingers crossed!!
Absolutely, ask about other certificates in the UK. I am module coordinator for the Improve Distance learning Cardio Cert and for the Liverpool CertAVP but I have limited knowledge of any others. Sadly, none combine theory with practical echo as far as I am aware.
Liz
Replying to Laura T. 14/11/2022 - 16:07
Hi Laura
Great to have you joining us. I hope that you find the course useful and I look forward to working with you over the coming weeks.
Liz
Replying to Kathryn B. 01/11/2022 - 11:59
Hi Kathryn (and everyone)
I made this little video running through the x-rays, so here it is. Let me know if you have any questions 🙂
Liz
https://drive.google.com/file/d/18AKFZw4OHuoMYZbtNyW7fUjuPaa4ID6o/view?usp=sharing
Replying to Kathryn B. 26/10/2022 - 08:18
In that case it’s this one! Sorry I couldn’t spot where I’d mentioned it.
https://onlinelibrary.wiley.com/doi/10.1111/jvim.15854
Liz
Replying to Kathryn B. 23/10/2022 - 20:25
Hi Kathryn,
Sorry for the delay and it was nice to ‘meet’ you last night. I’ve looked through my slides and my recording and I cannot see where I mention VHS and a paper, sorry! I do mention the VLAS score in association with a paper. It is:
https://avmajournals.avma.org/view/journals/javma/253/8/javma.253.8.1038.xml
It says you can tell if there is LA enlargement with a VLAS of >2.3 in the abstract but in the paper it is more accurate at >3.
In terms of osteomata/ vessels and neoplasia. This can be tricky. Osteomata tend to have a ventral distribution and are mineral opacity whereas vessels and neoplasia are usually soft tissue opacity. Ostemoata are also very small and there tends to be multiple of them. With vessels you can usually trace back to the origin or they overly a vessel as they turn the corner and come towards you. I guess the real solution is that if you are not sure to repeat the radiographs again in 3-4 weeks to see if there are any changes.
Liz
Replying to Sybil Dryburgh 23/10/2022 - 23:14
Hi both
Yes, this group originally did a retrospective study on this (although I’m not sure how you do a retrospective study about applying pressure and the presence or absence of a murmur!). They then went on to prove the concept with this prospective study.
In some cats, usually older and thinner cats, it is possible to place your stethoscope on the right parasternum and cause a low grade systolic murmur. The same goes with echo in some cats. When looking at the right ventricular outflow tract from the right side you can cause a dynamic obstruction due to the pressure of the probe. Another study (before we knew that some of these could be iatrogenic) back in 2004 showed that cats with dynamic right ventricular outflow tract obstruction didn’t have associated pathology or heart disease that would cause it. So, putting two and two together (and hopefully making 4) I think it would be safe to say that these cats probably don’t have pathology but due to their chest conformation you can push the heart against the opposite wall of the chest and deform the right outflow tract resulting in a murmur. When you release the pressure the murmur should disappear. Obviously, if it doesn’t disappear then another cause of the murmur might be present and if you’re not sure then echo is indicated.
I don’t think we know about dogs but I think the majority of dogs have too big a chest for this to be an issue (think how narrow cat chests are compared to a chihuahua even!)
Hopefully this answers your question but let me know if there are any others.
Liz
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