Multiple Congenital Cardiac Anomalies

Accession# 147266

Christina Copple, DVMMonday 2/28/2011

10mth, Male, Pomeranian Late January purchased from breeder with no

known prior medical concerns Episode after a moment of activity --- fell on

side, stiff, dilated pupils, unaware Recovered within minutes

Pants when excited or playing ER DVM: heart murmur & suspected PDA Specialty clinic: findings more consistent with

pulmonic stenosis Referral to NCSU for further evaluation

NCSU cardiology work-up Grade III/VI left apical systolic murmur Normal lung sounds Echocardiogram PCV/TS

Echocardiogram- Rt parasternal short-axis view of ventricles at level of papillary muscles

Severe right ventricular hypertrophy

Flattening of interventricular septum

Echocardiogram – M-mode through ventricles

Single narrow US beam of echoes as distance vs time

Provides time-dependent measurements

chamber dimension

RV hypertrophy RV wall thickness should be 1/3-1/2 that of the LV Lumen of LV normally ~3X diameter of RV lumen

Echocardiogram – Rt parasternal long-axis 4 chamber

view

RV hypertrophy, severe RA enlargement, moderate

Echocardiogram – Rt parasternal short-axis view at heart base of pulmonic valve (zoomed in)

Supravalvular pulmonic stenosis

Post stenotic dilation

Turbulent flow across stenosis

Echocardiogram – Lt parasternal short-axis view of pulmonic valve (payme view)

Echocardiogram – Lt parasternal short-axis view of pulmonic valve

Continuous wave Doppler signal

accurately evaluates high velocities without aliasing

Continuously sends and samples signal

spectral broadening expected as there is no discrimination between laminar vs turbulent flow

Echocardiogram – Lt parasternal short-axis view of pulmonic valve

Maximum velocity

Utilize modified Bernoulli equation

4V2

determine presssure gradient

Presssure gradient ~ 130 mmHg = severe as it is > 80

Echocardiogram – Lt parasternal apical 4 chamber

view

RA enlargement, moderate

Mild tricuspid insufficiency

Echocardiogram – Rt parasternal short-axis view of

ventricles at level of papillary muscles

BONUS Lesion!!

VSD – apical position in muscular septum

With right-to-left shunting

Echocardiogram – Lt parasternal apical 4 chamber

view of VSD with color Doppler

Contrast Echocardiogram – Bubble study with agitated saline!!

Uncommon forms of pulmonic stenosis & VSD Supraventricular pulmonic stenosis

Increased RVOT obstruction Rare, less common than valvular – Giant Schnauzers

Apical VSD in muscular septum Less common than perimembranous

Single opening in LV Multiple openings in RV

Right-to-left shunt due to elevated right sided pressures Decreased O2 content of systemic circulation Humans – neonates and small infants: uncommon,

usually present with heart failure & associated anomalies such as pulmonic stenosis, PDA, aortic coarctation, etc.

PCV = high normal Compensatory Episode either syncopal or cyanotic

What now? Balloon valvuloplasty?

Could help but….. Might result in altered pressure differential

between right and left sides Result in Left-to-Right shunt pulmonary

overcirculation

Amplatzer of VSD? Reduce potential for Left-to-Right shunt Not commonly performed Never performed at NCSU

References Fox, Philip R., Sisson, David, and Moise, N.

Sydney. Textbook of Canine and Feline Cardiology Principles and Clinical Practice. 2nd ed. W.B. Saunders Company. Philadelphia, PA. 1999.

Kumar K, Lock JE, and Geva T. Apical Muscular Ventricular Septal Defects Between The Left Ventricle And The Right Ventricular Infundibulum. Diagnostic And Interventional Considerations. Circualtion. 1997. March 4; 95(5):1207-1213.

Ramesh, et al. Transcatheter Closure of Congential Muscular Ventricular Septal Defect. JIntervenCardiol. 2004; 17:109-115.