Myocardial diseases Flashcards
(294 cards)
1
Q
HCM is characterized by unexplained ……… LV hypertrophy where the LV chamber is not dilated and is often ……. than normal.
A
HCM is characterized by unexpöained concentric LV hypertrophy where the LV chamber is not dilated and is often smaller than normal.
2
Q
HCM: …………… failure secondary to impaired relaxation is a common complication resulting in elevated LV ……….. pressure and a dilated LA chamber
A
HCM: Diastolic failure secondary to impaired relaxation is a common complication resulting in elevated LV filling pressure and a dilated LA chamber
3
Q
LV outflow obstruction is also a common occurrence.
A
LV outflow obstruction is also a common occurrence.
4
Q
The hypertrophy in cats displays varying morphology. Most cats present with symmetric hypertrophy with both the ventricular septum and the free wall affected to a similar degree. Figures 7.1 and 7.2
A
The hypertrophy in cats displays varying morphology. Most cats present with symmetric hypertrophy with both the ventricular septum and the free wall affected to a similar degree. Figures 7.1 and 7.2
About as many cats however, present with asymmetric hypertrophy affecting primarily the septum. Figures 7.3, 7.4).
Fewer cats (17%) present with asymmetric hypertrophy affecting the LV free wall. Figures 7.5 and 7.6.
5
Q
In other cases, only the apex, mid ventricular areas, segmental areas of marked transitions between normal thickness, and increased thickness or the very base of the septum are hypertrophied. Fig 7.7.
A
In other cases, only the apex, mid ventricular areas, segmental areas of marked transitions between normal thickness, and increased thickness or the very base of the septum are hypertrophied. Fig 7.7.
6
Q
Asymmetric septal hypertrophy was the most common form of hypertrophy in one study in dogs with HCM with 80% of 20 dogs in one study displaying this asymmetry.
A
Asymmetric septal hypertrophy was the most common form of hypertrophy in one study in dogs with HCM with 80% of 20 dogs in one study displaying this asymmetry.
7
Q
Infarction and aneurysmal dilation of the LV apex may develop.
Although this has not been studied in the cat, in man there is no correlation between the degree of hypertrophy and clinical signs of heart failure.
A
The degree of hypertrophy does correlate with the incidence of sudden death in man however.
8
Q
Hypertrophic cardiomyopathy:
Features:
Concentric LV hypertrophy
-Most have symmetric or just VS hypertrophy
LA does not have to be dilated.
Mot have obstruction to outflow
- SAM seen
- Systolic aortic valve closure seen
Elevated FS
A
Concentric LV hypertrophy
-Most have symmetric or just VS hypertrophy
LA does not have to be dilated.
Mot have obstruction to outflow
-SAM seen
Systolic aortic valve closure seen
Elevated FS
9
Q
The hypertrophy may obstruct flow in the LV outflow tract. This occurs primarily when?
A
When the base of the ventricular septum impinges upon the outflow tract, and it may occur when extensive free wall thickening displaces the mitral valve upward into the outflow tract.
10
Q
Abnormally long mitral valve leaflets are a cause of LV outflow obstruction in man. Cats with ……….hypertrophy or hypertrophy primarily affecting the ……… tend to have a significantly higher incidence of murmurs, probably associated with outflow tract obstruction.
A
Abnormally long mitral valve leaflets are a cause of LV outflow obstruction in man. Cats with symmetric hypertrophy or hypertrophy primarily affecting the septum tend to have a significantly higher incidence of murmurs, probably associated with outflow tract obstruction.
11
Q
hearts with mid ventricular hypertrophy may have mid cavity obstruction associated with contraction.
A
hearts with mid ventricular hypertrophy may have mid cavity obstruction associated with contraction.
12
Q
Significant …… hypertrophy in addition to the LVH has been seen in several cats.
A
Significant RV hypertrophy in addition to the LVH has been seen in several cats.
13
Q
large prominent papillary muscles are common in cats with HCM. Using either of the area methods to measure papillary muscle size, a papillary muscle area of greater than …. cm upphöjt i 2 exceeds that found in normal cats.
A
0.8
Fig 7.8
This is not specific to HCM and may reflect enlargement of the papillary muscles secondary to other causes of LV hypertrophy.
14
Q
Left atrial size may or may not be increased in animals with HC;. LA enlargement is considered to be an indicator of severity and chronicity of diastolic failure in man. The larger the LA, the worse the prognosis. The cause of LA enlargement is typically secondary to ……….. dysfunction but may be because of …………..failure or abnormal mitral valve function.
A
The cause of LA enlargement is typically secondary to diastolic dysfunction but may be because of systolic failure or abnormal mitral valve function.
15
Q
LV outflow obstruction:
Systolic anterior motion (SAM) of the mitral valve occurs in the presence of moderate to severe LV outflow tract obstruction. Several theories exist for the underlying cause of SAM. Such as?
A
High velocity flow within an outflow tract narrowed by a hypertrophied septum creates a Venturi effect and tends to pull one or both mitral valve leaflets into the outflow tract.
The presence of abnormal ventricular architecture and papillary muscle misalignment may allow the septal or parietal mitral valve leaflets to be pushed into the outflow tract during systole.
Alignment of the sub auricular papillary muscle into the middle of the ventricular chamber may also play a role in the development of SAM. This displacement causes the flow of blood to slip in under the septal leaflet pushing it into the outflow tract like a cowl.
16
Q
In man reports of elongated mitral leaflet, direct papillary muscle attachment to the septal mitral leaflet, and ……… chordae tendinae are all associated with obstruction to LV outflow.
A
In man reports of elongated mitral leaflet, direct papillary muscle attachment to the septal mitral leaflet, and short chordae tendinae are all associated with obstruction to LV outflow.
17
Q
There is reason to believe that ………..contributes substantially more to any outflow obstruction than the …………………
A
There is reason to believe that SAM contributes substantially more to any outflow obstruction than the hypertrophied ventricular septum.
18
Q
Systolic anterior motion of the ………….. mitral valve leaflet secondary to a hyperdynamic state without LV hypertrophy has been documented.
A
Systolic anterior motion of the parietal mitral valve leaflet secondary to a hyperdynamic state without LV hypertrophy has been documented.
19
Q
Outflow tract obstruction is worsened by volume ……….., decreased …………. (aortic pressure), and increased ………….., which all allow the LV chamber to achieve smaller systolic dimensions and ………….tension on chordae teninae allowing the mitral valve leaflet to move up into the outflow tract.
A
Outflow tract obstruction is worsened by volume contraction, decreased afterload (aortic pressure), and increased contractility, which all allow the LV chamber to achieve smaller systolic dimensions and decrease tension on chordae teninae allowing the mitral valve leaflet to move up into the outflow tract.
20
Q
The degree and duration of ………………….during systolic anterior mitral valve motion correlate with severity of dynamic outflow obstruction.
A
The degree and duration of septal contact during systolic anterior mitral valve motion correlate with severity of dynamic outflow obstruction.
21
Q
Although muscular septal hypertrophy and SAM are the most common causes of LV obstruction, mid ventricular obstruction may occur. This is usually caused by?
A
This is usually caused by severe hypertrophy that allows the septum and free wall to meet each other during systole resulting in cavity obliteration.
22
Q
Often a severely hypertrophied papillary muscle is caught between the 2 walls. Identification of mid ventricular obstruction is possible with color-flow Doppler that shows turbulence within the ……….. of the ventricular chamber and with PW Doppler, that defines an aliased signal at the point of obstruction.
A
Often a severely hypertrophied papillary muscle is caught between the 2 walls. Identification of mid ventricular obstruction is possible with color-flow Doppler that shows turbulence within the middle of the ventricular chamber and with PW Doppler, that defines an aliased signal at the point of obstruction.
23
Q
The increase in mid ventricular velocity may not reflect true obstruction and may simply be the result of high velocity flow secondary to a ………………….. chamber.
A
The increase in mid ventricular velocity may not reflect true obstruction and may simply be the result of high velocity flow secondary to a small hyper dynamic chamber.
24
Q
An experienced eye can detect systolic anterior motion on real-time 2 D images, but the motion is easier to detect and document on M-mode images of the mitral valve.
A
Fig 7.12
25
The duration of mitral valve septal contact is directly correlated to severity of the outflow tract gradient.
The duration of mitral valve septal contact is directly correlated to severity of the outflow tract gradient.
26
Longer apposition with the septum indicates .............?
Longer apposition with the septum indicates more severe obstruction.
27
.......... peaking SAM with little if any contact suggests mild obstruction to flow. Small gradients will not create any SAM.
Late peaking SAM with little if any contact suggests mild obstruction to flow. Small gradients will not create any SAM.
28
LV outflow obstruction because of SAM is ............. in nature and may not be present at rest.
LV outflow obstruction because of SAM is dynamic in nature and may not be present at rest.
29
Systolic anterior motion may be the cause of LV outflow obstruction and the resultant concentric LV hypertrophy in young dogs.
Systolic anterior motion may be the cause of LV outflow obstruction and the resultant concentric LV hypertrophy in young dogs.
30
The systolic anterior mitral valve motion may be due to abnormalities of the mitral apparatus in dog. ........... valve tissue has been seen in several of the dogs with SAM.
Redundant valve tissue has been seen in several of the dogs with SAM.
The hypertrophy and systolic anterior motion resolved with beta-blocker treatment in dogs that lived.
31
It is important to point out that SAM may be seen in patients without HCM. It is reported in patients with elevated RV pressure caused by ..................(3)
It is important to point out that SAM may be seen in patients without HCM. It is reported in patients with elevated RV pressure caused by pulmonic stenosis, tetralogy of Fallot, and pulmonary hypertension.
All of these patients had LV volume contraction, and the abnormal LV geometry is thought ot be the cause of the SAM.
Outflow gradients were present in most cases and even when peak flow velocity was normal, the flow profile showed lated peaking velocity.
32
Systolic anterior mitral valve motion is also reported in association with a handful of other situations; transposition, double chamber right ventricle. anomalous papillary muscles, conotruncal abnormalities, systemic hypertension, and anemia.
Systolic anterior mitral valve motion is also reported in association with a handful of other situations; transposition, double chamber right ventricle. anomalous papillary muscles, conotruncal abnormalities, systemic hypertension, and anemia.
33
SAM may be seen with RV pressure ............. presumably due to poor LV ................ and altered LV geometry.
SAM may be seen with RV pressure overload presumably due to poor LV preload and altered LV geometry.
34
Aortic valve motion may be altered in people and cats with hypertrophic obstructive cardiomyopathy.
Aortic valve motion may be altered in people and cats with hypertrophic obstructive cardiomyopathy.
35
Ejection time increase in direct proportion to the degree of subvalvular dynamic obstruction.
There is evidence of early systolic closure of the aortic valve corresponding to the ..........in forward flow as the dynamic obstruction occurs.
This motion is also called?
Ejection time increase in direct proportion to the degree of subvalvular dynamic obstruction.
There is evidence of early systolic closure of the aortic valve corresponding to the decrease in forward flow as the dynamic obstruction occurs.
Fig 4.97, 7.13
This motion is also called mid systolic notching or mid systolic closure.
36
This aortic valve motion usually involves only 1 or 2 of the aortic cusps, and M-mode images of the aortic valve taken from parasternal long-axis views may not show it while M-modes obtained from transverse views may.
This motion may be seen with? (2)
This motion may be seen with dynamic hypertrophic obstructive cardiomyopathy or with fixed sub aortic obstruction (stenosis).
there is no correlation with the severity of the pressure gradient. Early aortic valve closure has been reported with ventricular septa defect, and double outlet right ventricle.
37
Systolic function:
| Fractional shortening in HCM is typically increased and the hearts are very visibly .........
hyperdynamic. Fig 7.2
This is not necessarily indicative of increased intrinsic contractility but may only be secondary to altered loading conditions in the heart. Paradoxically this increase in function often impedes cardiac output as dynamic obstruction is aggravated by the hyper contractile septum.
38
Only in rare cases, as end-stage HCM is reached, does function of the septum or free wall decrease. With advances in tissue Doppler imaging systolic dysfunction can be identified before FS and EF decrease.
With advances in tissue Doppler imaging systolic dysfunction can be identified before FS and EF decrease.
39
In one study, 72% of cats with FS less than 30% were dead 3 months after their initial examination.
Fig 7.14, 7.15
40
Whether these cats have reduced FS because of systolic dysfunction alone or diastolic disease, which has progressed to include systolic dysfunction, is not known.
Whether these cats have reduced FS because of systolic dysfunction alone or diastolic disease, which has progressed to include systolic dysfunction, is not known.
41
Doppler evaluation of HCM:
A pressure gradient across the LV outflow tract in man is now considered a predictor of complications, disease progression, and death. This predictive feature was present when outflow gradients reached ........ mm or greater, and prognosis did not become worse with worsening pressure gradients.
This predictive feature was present when outflow gradients reached 30 mm or greater, and prognosis did not become worse with worsening pressure gradients.
42
There also appears to be a direct relationship between LV outflow obstruction and both systolic and diastolic dysfunction in humans with HCM. The gradient correlated with LV filling pressure, hypertrophy, and LA size.
There also appears to be a direct relationship between LV outflow obstruction and both systolic and diastolic dysfunction in humans with HCM. The gradient correlated with LV filling pressure, hypertrophy, and LA size.
43
The obstruction to outflow seen in many cases of HCM occurs primarily during ..................
The obstruction to outflow seen in many cases of HCM occurs primarily during late systole.
44
Spectral Doppler displays show the outflow obstruction in late systole nicely by dagger-shaped late peaking velocity on LV outflow-tract flow profiles.
Spectral Doppler displays show this nicely by dagger-shaped late peaking velocity on LV outflow-tract flow profiles. Fig 7.16.
45
Spectral Doppler displays show this nicely by dagger-shaped late peaking velocity on LV outflow-tract flow profiles. Fig 7.16.
This late-peaking maximal velocity correlates with the increased flow velocity as the .......... narrows the outflow tract or .......obstructs flow.
This late-peaking maximal velocity correlates with the increased flow velocity as the septum narrows the outflow tract or SAM obstructs flow.
46
Pressure gradients are measured sing the .....
Bernoulli equation
47
Outflow obstruction is subvalvular, and the Doppler cursor is not necessarily aligned with the wall of the aorta to record peak velocity.
Outflow obstruction is subvalvular, and the Doppler cursor is not necessarily aligned with the wall of the aorta to record peak velocity.
Align the cursor with the outflow tract, using CF Doppler do define the orientation of the turbulent flow. A low frequency transducer may define high outflow flow velocity that is not found with high frequency high-resolution transducers.
48
Occasionally there is obstruction in the middle of the ventricular chamber. A late-peaking outflow profile is sen if the middle of the chamber is interrogated or when the CW Doppler beam crossed that portion of the chamber while evaluating the outflow tract. PW Dopler should be used to interrogate the midventruuclar area for obstruction. CF Doppler aids in identifying this.
Occasionally there is obstruction in the middle of the ventricular chamber. A late-peaking outflow profile is sen if the middle of the chamber is interrogated or when the CW Doppler beam crossed that portion of the chamber while evaluating the outflow tract. PW Dopler should be used to interrogate the midventruuclar area for obstruction. Fig 7.16.
CF Doppler aids in identifying this.
49
Midventricular obstruction should be considered when there is no SAM and secondary......... but there is a murmur.
Midventricular obstruction should be considered when there is no SAM and secondary MR but there is a murmur.
50
Late peaking ventricular outflow profiles are seen with dynamic outflow obstructions.
Late peaking ventricular outflow profiles are seen with dynamic outflow obstructions.
51
Systolic anterior motion is not only responsible for obstruction to LV outflow, but also for resultant mild to moderater MR as the valve leaflets are pulled out of a properly closed position. The MR jet is directed toward the lateral wall of the LA, and seeing a jet directed ............ from the outflow tract should provide a hitch that SAM is present.
The MR jet is directed toward the lateral wall of the LA, and seeing a jet directed away from the outflow tract should provide a hitch that SAM is present.
Figures 7.17, 7.18
52
The presence and degree of regurgitation is directly related to SAM. The greater the obstruction, the greater the degree of SAM the greater the degree of insufficiency.
The presence and degree of regurgitation is directly related to SAM. The greater the obstruction, the greater the degree of SAM the greater the degree of insufficiency.
53
Alleviation of the outflow tray obstruction results in reduction or elimination of the SAM and MR:
Alleviation of the outflow tray obstruction results in reduction or elimination of the SAM and MR:
54
There are patients with MR unrelated to their hypertrophic disease however, and this should be suspected when?
When the regurgitant jet is not directed downward toward the lateral wall of the LA away from the outflow tract and is centrally directed instead.
55
When color-flow or an imaging Doppler probe is not used, it is easy to record MR flow as opposed to LV outflow from left apical 5 ch views of the heart.
When color-flow or an imaging Doppler probe is not used, it is easy to record MR flow as opposed to LV outflow from left apical 5 ch views of the heart.
56
MR starts ............. in the cardiac cycle near the beginning of the QRS complex. When the late-peaking flow profile is seen, you know it is the ........... and not MR.
MR starts earlier in the cardiac cycle near the beginning of the QRS complex. When the late-peaking flow profile is seen, you know it is the outflow tract and not MR.
57
Evaluation of Diastolic function:
PW Doppler Evaluation of ...... function. While systolic function is generally not impaired in patients with HCM, ........... dysfunction is a common abnormality.
PW Doppler Evaluation of diastolic function. While systolic function is generally not impaired in patients with HCM, diastolic dysfunction is a common abnormality.
58
Diastolic dysfunction is the result of impaired myocardial relaxation, restriction to LV filling, and increased LV filling pressures.
Diastolic dysfunction is the result of impaired myocardial relaxation, restriction to LV filling, and increased LV filling pressures.
59
............failure is a major factor in the development of congestive heart failure in feline cardiomyopathy.
Diastolic failure is a major factor in the development of congestive heart failure in feline cardiomyopathy.
60
Assessment of LV diastolic function involves the Doppler evaluation of transmitral flow, isovolumic relaxation time, pulmonary venous flow, and myocardial motion.
Assessment of LV diastolic function involves the Doppler evaluation of transmitral flow, isovolumic relaxation time, pulmonary venous flow, and myocardial motion.
61
Impaired myocardial relaxation is reflected in the rate of relaxation, and isovolumic relaxation time will be ...................
Impaired myocardial relaxation is reflected in the rate of relaxation, and isovolumic relaxation time will be increased.
62
The LV filling patterns of most patients, both animals and human with HCM, is abnormal. It shows?
Decreased early filling (E) and a larger late diastolic filling component (A) with the atrial contraction. Figures 4.73, 7.19, 7.20
63
Mitral valve early diastolic deceleration time is ........... in HCM, and this is reported as an early predictor of disease development.
Mitral valve early diastolic deceleration time is prolonged in HCM, and this is reported as an early predictor of disease development.
64
HCM: The increased deceleration time reflects impaired LV filling associated with delayed relaxation and results in a larger atrial contribution to LV volume and a decreased E:A.
The increased deceleration time reflects impaired LV filling associated with delayed relaxation and results in a larger atrial contribution to LV volume and a decreased E:A.
Increased heart rate results in summation of E and A transmitral flow.
65
The summated EA has higher flow velocity than isolated E flow velocity in the same cat.
The summated EA has higher flow velocity than isolated E flow velocity in the same cat.
66
The sum of individual E and A velocities in cats with slow heart rates is similar to the summated EA flow velocity in normal cats.
The sum of individual E and A velocities in cats with slow heart rates is similar to the summated EA flow velocity in normal cats.
67
As discussed in chapter 4, diastolic dysfunction is a continuum of events, and flow profiles will transition through a pseudonormal phase into a patterns of restrictive physiology typical of decreased compliance. Table 4.3
As discussed in chapter 4, diastolic dysfunction is a continuum of events, and flow profiles will transition through a pseudonormal phase into a patterns of restrictive physiology typical of decreased compliance. Table 4.3
68
```
Diastolic failure in HCM:
Impaired relaxation indicated by:
-............. IVRT
-............MV E peak
-Pulmonary vein Ar flow of ........... duration and ...................... velocity.
```
- Increased IVRT
- Decreased MV E peak
- Pulmonary vein Ar flow of increased duration and increased velocity.
69
Acceleration and deceleration times of systolic pulmonary venous flow into the LA is also evaluated.
Acceleration and deceleration times of systolic pulmonary venous flow into the LA is also evaluated.
70
Whereas parameters assessing LV filling patterns are similar in human patients with HCM and hypertrophic heart disease secondary to aortic stenosis and systemic hypertension, ....................... flow differs between idiopathic HCM secondary forms of hypertrophy
Whereas parameters assessing LV filling patterns are similar in human patients with HCM and hypertrophic heart disease secondary to aortic stenosis and systemic hypertension, pulmonary venous flow differs between idiopathic HCM secondary forms of hypertrophy
71
Patients with HCM have decreased systolic acceleration times, increased deceleration times and reduced rate of systolic deceleration.
Patients with HCM have decreased systolic acceleration times, increased deceleration times and reduced rate of systolic deceleration.
72
Patients with secondary forms of hypertrophy had parameters similar to ...............?
Patients with secondary forms of hypertrophy had parameters similar to normal controls.
73
There is no difference in the pulmonary venous flow velocities, acceleration or deceleration times, or rates between human patients with obstructive versus non-obstrcutive HCM, not between the varying patterns of hypertrophy (asymmetric, symmetric, and apical).
There is no difference in the pulmonary venous flow velocities, acceleration or deceleration times, or rates between human patients with obstructive versus non-obstrcutive HCM, not between the varying patterns of hypertrophy (asymmetric, symmetric, and apical).
74
Pulmonary venous flow is used to differentiate normal from pseudonormal transmittal flow and isovolumic relaxation times. In the presence of elevated LV filling pressure, secondary to impaired relaxation, despite normal IVRT and normal transmitral flow, there will be enhanced ............. into the pulmonary vein during the atrial contraction.
In the presence of elevated LV filling pressure, secondary to impaired relaxation, despite normal IVRT and normal transmitral flow, there will be enhanced reverse flow into the pulmonary vein during the atrial contraction.
This includes both duration of reverse flow and velocity of reverse flow.
75
Systolic pulmonary venous flow may be ....... in the presence of elevated LA pressure, and diastolic flow will be ........... than systolic flow as the atrial component of filling plays a more dominant role.
Systolic pulmonary venous flow may be decreased in the presence of elevated LA pressure, and diastolic flow will be greater than systolic flow as the atrial component of filling plays a more dominant role.
Fig 7.21
76
Pseudonormal diastolic function:
MV flow appears ............
IVRT ...........:
use pulmonary vein flow to identify pseudonormal diastolic function
-Ar flow increased in duration and velocity
MV flow appears normal
-IVRT normal:
use pulmonary vein flow to identify pseudonormal diastolic function
-Ar flow increased in duration and velocity
77
TDI evaluation of diastolic function:
Tissue Doppler Evaluation of diastolic function:
Tissue Doppler imaging is able to define abnormalities of ......... and ............ function in the myocardium.
Tissue Doppler imaging is able to define abnormalities of systolic and diastolic function in the myocardium.
78
TDI:
Hypertrophic cardiomyopathy has abnormal ...............systolic shortening (reduced systolic annular velocity) and abnormal diastolic .............. (reduced early diastolic annular velocity) and abnormal diastolic ............... (reduced early diastolic annular velocity), which can be documented with TDI
Hypertrophic cardiomyopathy has abnormal longitudinal systolic shortening (reduced systolic annular velocity) and abnormal diastolic lenghtening (reduced early diastolic annular velocity) and abnormal diastolic lengthening (reduced early diastolic annular velocity), which can be documented with TDI
79
TDI has the ability to identify subclinincal HCM in asymptomatic patients and provide a measure of LV filling pressure in man.
TDI has the ability to identify subclinincal HCM in asymptomatic patients and provide a measure of LV filling pressure in man.
80
Annular systolic and diastolic velocities are lower in human patients with subclinical hypertrophic cardiomyopathy even before the development of any LV hypertrophy.
Annular systolic and diastolic velocities are lower in human patients with subclinical hypertrophic cardiomyopathy even before the development of any LV hypertrophy. Some of these parameters have been studies in the cat, and the differences in PW tissue Doppler parameters between cats with HCM and normal cats are listed in Tables 7.1, 7.2 and 7.3
81
TDI:
Cats with HCM have lower...... at all apical 4 ch locations, and lower ....... at all myocardial locations, lower ......at both sides of the mitral annulus and at the chordal level in the ventricular septum on the apical 4 ch view, lower S' at both sides of the mitral annuls, and at the chordal level i the ventricular septum on the apical 4 ch view, lower E' acceleration and deceleration rates at all locations on the apical vies and in the LV free wall on the apical 4 ch view.
Cats with HCM have lower E´at all apical 4 ch locations, and lower
E´:A´at all myocardial locations, lower Se´at both sides of the mitral annulus and at the chordal level in the ventricular septum on the apical 4 ch view, lower S' at both sides of the mitral annuls, and at the chordal level i the ventricular septum on the apical 4 ch view, lower E' acceleration and deceleration rates at all locations on the apical vies and in the LV free wall on the apical 4 ch view. Fig 7.22
82
Asymptomatic cats with HCM have increased ......... velocity in the ventricular septum on both apical and parasternal 4 ch views. This probably reflects preserved or increased atrial contractility in the setting of high LA pressure.
Asymptomatic cats with HCM have increased A' velocity in the ventricular septum on both apical and parasternal 4 ch views. This probably reflects preserved or increased atrial contractility in the setting of high LA pressure.
83
Several systolic and diastolic time intervals are also significantly different in HCM cats when compared to normal cats. These parameters show that peak early PW .................. myocardial velocity is both decreased and occurs later in the diastolic time period, and that isovolumic relaxation times are ............. in cats with HCM.
Several systolic and diastolic time intervals are also significantly different in HCM cats when compared to normal cats. These parameters show that peak early PW diastolic myocardial velocity is both decreased and occurs later in the diastolic time period, and that isovolumic relaxation times are prolonged in cats with HCM.
84
Specific differences in cats with HCM from normal cats are as follows; there is longer E´acceleration time at both sides of the mitral annulus on the apical view and the LV free wall at the chordal level on both apical and right parasternal 4 ch views, longer E´ deceleration time at the free wall mitral annulus on the apical 4 ch and on the right parasternal 4 ch imaging plane at the level of the chordae in the free wall, longer early systolic (se´) acceleration time at all locations on apical 4 ch views except at the septal annulus, longer E´duration at the free wall mitral annulus and free wall chordal level on both imaging planes, and longer time interval between the start of Se´to start of late systolic motion (Sl´) at the free wall annulus on the apical view and at the chordal level of the septum on the right parasternal 4 ch plane.
there is longer E´acceleration time at both sides of the mitral annulus on the apical view and the LV free wall at the chordal level on both apical and right parasternal 4 ch views, longer E´ deceleration time at the free wall mitral annulus on the apical 4 ch and on the right parasternal 4 ch imaging plane at the level of the chordae in the free wall, longer early systolic (se´) acceleration time at all locations on apical 4 ch views except at the septal annulus, longer E´duration at the free wall mitral annulus and free wall chordal level on both imaging planes, and longer time interval between the start of Se´to start of late systolic motion (Sl´) at the free wall annulus on the apical view and at the chordal level of the septum on the right parasternal 4 ch plane.
85
Isovolumic relation time at all locations on the apical 4 ch view using PW tissue Doppler is also .............in cats with HCM.
longer
86
TDI changes from normal are also evident in subclinical dystrophic-deficient HCM even before the presence of any documented hypertrophic changes.
TDI changes from normal are also evident in subclinical dystrophic-deficient HCM even before the presence of any documented hypertrophic changes.
87
Early evidence of impaired diastolic function included decreased radial and longitudinal lateral wall annular E´, increased longitudinal lateral wall annular A', and lengthened longitudinal lateral wall and radial isovolumic relaxation times.
The E':A' relationship in these cats was less than........in most cats for radial motion and all cats for longitudinal motion of the lateral wall. These changes were more prominent at the ........... than the apex and in the ............ than the epicardium. This may indicate that ...............fibers are affected earlier in the course of the disease than ..................fibers.
The E':A' relationship in these cats was less than 1 in most cats for radial motion and all cats for longitudinal motion of the lateral wall. These changes were more prominent at the base than the apex and in the endocardium than the epicardium. This may indicate that longitudinal fibers are affected earlier in the course of the disease than radial fibers.
88
Postsystolic contraction can be seen in man with myocardial ischemia and was seen in several of the dystrophic cats. It is thought to represent impairment of .............. function, but its mechanism is not fully understood.
This systolic motion is present ...... in systole or ........... in diastole rather than during early systole. This contraction often occurs during the time when early diastolic motion should occur resulting in the absence of an ............ wave.
It is thought to represent impairment of systolic function, but its mechanism is not fully understood.
This systolic motion is present late in systole or early in diastole rather than during early systole. This contraction often occurs during the time when early diastolic motion should occur resulting in the absence of an E´ wave.
89
Depressed systolic function despite normal systolic dimension and normal FS was also verified by decreased S´ motion on ............. but not ................myocardial fibers.
Depressed systolic function despite normal systolic dimension and normal FS was also verified by decreased S´ motion on longitudinal but not radial myocardial fibers.
One study reports that decreased S' in the longitudinal fibers of cats with HCM is seen only in symptomatic cats with HCM
90
The differences in longitudinal early ................wall motion between segments of the septum and the free wall seen in normal feline hearts is no longer present in most portions of the myocardium in cats with HCM.
The differences in longitudinal early diastolic wall motion between segments of the septum and the free wall seen in normal feline hearts is no longer present in most portions of the myocardium in cats with HCM.
This heterogeneity in myocardial motion along the longitudinal axis is though to be an important component for optimal myocardial function.
91
Nonunitormity in myocardial motion that is lost in cats with HCM include?
The E´acceleration rate of the interventricular septum at the chordae level is greater than the acceleration rate at the septal mitral annulus on apical 4 ch imaging planes and the E´ acceleration time was decreased at the chordal level when compared to the level of the mitral annulus of the septum.
92
Cats with HCM have greater ..........ratios at the LV free wall when compared to the septum on right parasternal long-axis 4 ch views.
Cats with HCM have greater E´:A´ ratios at the LV free wall when compared to the septum on right parasternal long-axis 4 ch views.
93
TDI in HCM
.......... E´at all apical locations
........ E´:A at all apical locations
.......... S´ at all apical locations
Lower E´at all apical locations
Lower E´:A at all apical locations
Lower S´ at all apical locations
94
Summation of early and late diastolic motion is seen at rapid heart rates. Summated EA´ has higher velocity than when .............
Summation of early and late diastolic motion is seen at rapid heart rates. Summated EA´ has higher velocity than when they are separate.
One study shows that this does not affect the interpretation of myocardial velocity when compared to cats without heart disease and rapid heart rates.
95
Another study found that if the summated EA´was compared to the sum of E´and A´when existing separately in cats with slower heart rates, there was no significant difference. Therefore, summated EA´myocardial velocity and summated EA transmitral flow may potentially be used to assess diastolic function in cats with HCM.
Therefore, summated EA´myocardial velocity and summated EA transmitral flow may potentially be used to assess diastolic function in cats with HCM.
96
It is important to use different reference ranges in order to interpret summated and non-summated diastolic tissue Doppler variables.
It is important to use different reference ranges in order to interpret summated and non-summated diastolic tissue Doppler variables.
97
When early diastolic motion is decreased and summated with a potentially increased late diastolic velocity, the interpretation of events can become difficult. There is up to 30% variation in these variables from study to study, and small changes in tissue velocity should not be over interpreted as a significant change unless a trend is established.
When early diastolic motion is decreased and summated with a potentially increased late diastolic velocity, the interpretation of events can become difficult. There is up to 30% variation in these variables from study to study, and small changes in tissue velocity should not be over interpreted as a significant change unless a trend is established.
98
PW tissue Doppler of the right side of the heart exhibits some differences from normal in cats with HCM. The E´velocity is ............. at the tricuspid valve annulus and the A´velocity is ............... in cats with HCM when compared to normal cats.
PW tissue Doppler of the right side of the heart exhibits some differences from normal in cats with HCM. The E´velocity is decreased at the tricuspid valve annulus and the A´velocity is increased in cats with HCM when compared to normal cats.
99
Early diastolic myocardial velocity is preload dependent and can be used to identify diastolic failure in cats with ...................transmitral flow profiles.
Early diastolic myocardial velocity is preload dependent and can be used to identify diastolic failure in cats with pseudonormal transmitral flow profiles.
100
An E´value of >........ cm/sec separates normal feline hearts from hearts with HCM.
An E´value of > 7.2 cm/sec separates normal feline hearts from hearts with HCM.
Figures 7.22 and 7.23
This value has a specificity of 87% and a sensitivity of 92%
101
Diastolic pressure in the LA affects the PW Doppler transmitral flow profile and velocity.
Diastolic pressure in the LA affects the PW Doppler transmitral flow profile and velocity.
102
Early diastolic longitudinal myocardial velocity is affected by LV filling pressure.
The relationship of E:E´ is strongly correlated to LV ............... in man and in cats.
The relationship of E:E´ is strongly correlated to LV filling pressure in man and in cats.
103
Normal E´ is > ........ cm/sec and normal E:E´is
Normal E´ is > 7.2 cm/sec and normal E:E´is
104
TDI:
| E´
E´
105
In man, the degree of LV outflow obstruction is significantly correlated with poorer systolic and early diastolic myocardial motion and a higher E:E´
In man, the degree of LV outflow obstruction is significantly correlated with poorer systolic and early diastolic myocardial motion and a higher E:E´
106
Overall Assessment of Diastolic dysfunction:
Grades of diastolic dysfunction have been established in man.The parameters used to assign a grade include?
Transmitral flow
Pulmonary venous flow
Tissued Doppler
Size of LA
These parameters allow indirect evaluation of relaxation, compliance, atrial function, and LV filling pressure.
107
Complications:
| Thrombus may form within the LA (figures 7.24-7.26)
Complications:
| Thrombus may form within the LA (figures 7.24-7.26)
108
LA dilation seems to be a risk factor for the development of arterial thromboembolism, although statistically this is not supported.
LA dilation seems to be a risk factor for the development of arterial thromboembolism, although statistically this is not supported.
Thrombus formation in the LA is reported in 13 to 17% of cats with clinically diagnosed HCM, and 41% of cats post mortem
109
Thrombus forms within the left ............. in cats with dilated LA chambers secondary to stasis of blood.
Thrombus forms within the left auricular appendage in cats with dilated LA chambers secondary to stasis of blood.
110
Cats with LA size greater than .......mm are thought to be predisposed to the development of arterial thromboembolism, but a recent study found that the atrial size in many cats with thromboembolic disease was as small as ......... mm.
Cats with LA size greater than 20 mm are thought to be predisposed to the development of arterial thromboembolism, but a recent study found that the atrial size in many cats with thromboembolic disease was as small as 14 mm.
111
............ analysis of left auricular flow can provide evidence for the potential formation of spontaneous echo contrast or thrombus formation in man and in cats.
PW Doppler analysis of left auricular flow can provide evidence for the potential formation of spontaneous echo contrast or thrombus formation in man and in cats.
112
PW Doppler flow velocity lower than ................. m/sec is correlated with stasis of blood flow and a high possibility of thrombus formation.
PW Doppler flow velocity lower than 0.25 m/sec is correlated with stasis of blood flow and a high possibility of thrombus formation.
113
Low to nonexistent auricular flow velocities are a sign of significant left auricular dysfunction.
Low to nonexistent auricular flow velocities are a sign of significant left auricular dysfunction.
114
Ischemia and effusion:
Myocardial ischemia may be seen on occasion in cats with HCM: Initially only depressed ........... thickening of either the septum of LV free wall is seen.
Myocardial ischemia may be seen on occasion in cats with HCM: Initially only depressed systolic thickening of either the septum of LV free wall is seen.
115
Chronic ischemia may lead to infarction, and a regional area of hypokinesis with thin walls and potentially an aneurysmal dilatation may be seen.
Chronic ischemia may lead to infarction, and a regional area of hypokinesis with thin walls and potentially an aneurysmal dilatation may be seen.
116
Fractional shortening may be .................. in these cats if the M-mode measurement incorporated this portion of the ventricle. This is typically seen as a sequela to severe long-standing disease.
Fractional shortening may be reduced in these cats if the M-mode measurement incorporated this portion of the ventricle. This is typically seen as a sequela to severe long-standing disease.
117
Severe long-standing HCM disease may result in depressed function and areas of myocardial ischemia and infarction.
Severe long-standing HCM disease may result in depressed function and areas of myocardial ischemia and infarction.
118
Pericardial effusion may be seen in cats with severe HCM and clinical signs of heart failure. Pleural effusion and dyspnea are also often seen as a presenting compliant in cats with HCM:
Pericardial effusion may be seen in cats with severe HCM and clinical signs of heart failure. Pleural effusion and dyspnea are also often seen as a presenting compliant in cats with HCM:
Fig 7.28, 7.29
119
Pericardial effusion may be seen in cats with CHF second to HCM. If the effusion is not seen behind the LA but only around the RV wall; this helps diff ................ effusion.
diff pleural form pericardial effusion.
120
Other causes of hypertrophy:
True HCM is idiopathic, and the presence of other diseases that may lead to potentially reversible LV hypertrophy should be ruled out. These include?
Systemic hypertension
A common sequela of chronic renal failure seen so often in older cats
Hyperthyroidism
121
Hyperthyroidism causes hypertrophy of the septum and wall.
Hyperthyroidism causes hypertrophy of the septum and wall. One study showed free wall hypertrophy in 72% of cats with hyperthyroidism while sonly 40% of them had septal hypertrophy.
Seventy procent of these same cats also had LA dilation. Almost 50% of these cats are reported to have an increase in ventricular diastolic chamber size.
122
The vast majority of cats have hyperdynamic wall and septal motion and increased fractional shortenings. While there appears to be some differences between idiopathic and non-idiopathic LV hypertrophy in the cat, there is no reliable M-mode or 2D echo way to differentiate between these causes of hypertrophy. They may even coexist.
The vast majority of cats have hyperdynamic wall and septal motion and increased fractional shortenings. While there appears to be some differences between idiopathic and non-idiopathic LV hypertrophy in the cat, there is no reliable M-mode or 2D echo way to differentiate between these causes of hypertrophy. They may even coexist.
123
The degree of hypertrophy, the incidence of SAM, and the degree of outflow obstruction are similar in both hypertensive and idiopathic hypertrophic cardiomyopahty patients in man.
The degree of hypertrophy, the incidence of SAM, and the degree of outflow obstruction are similar in both hypertensive and idiopathic hypertrophic cardiomyopahty patients in man.
The presence of hypertension in conjunction with HCM usually results in a more significant hypertrophy however.
124
There are also irreversible causes of LV hypertrophy that can mimic HCM. These include?
Hypertrophic feine muscular dystrophy and other infiltrative disorders
125
In man, TDI has been shown to help differentiate between pathologic LV hypertrophy (HCM, hypertension), and the hypertrophy found in athletic hearts. Athletic hearts showed?
Normal systolic and diastolic annular myocardial velocities while they are altered in the pathologic forms.
126
Rule out reversible causes of hypertrophy such as?
Hypertension and hyperthyroidism. They cannot be differentiated from HCM echocardiographically
127
An unusual presentation for cats with hyperthryroidim is left an right ventricular chamber dilation with normal wall and septal thickness and poor fractional shortening. This is thought to occur secondary to increased ............and.................. with chronic hyperthyroidism leading to congestive heart failure. Even these changes are reversible to a certain degree as the hyperthyroid state is corrected.
An unusual presentation for cats with hyperthryroidim is left an right ventricular chamber dilation with normal wall and septal thickness and poor fractional shortening. This is thought to occur secondary to increased systolic wall stress and myocardial dysfunction with chronic hyperthyroidism leading to congestive heart failure. Even these changes are reversible to a certain degree as the hyperthyroid state is corrected
128
Dynamic right ventricular outflow obstruction (DRVO):
The cause of the obstruction is not well defined and may simply be secondary to excessive hypertrophy of the right ventricular wall or septum into the right ventricular outflow tract or cavity.
Dynamic right ventricular outflow obstruction:
The cause of the obstruction is not well defined and may simply be secondary to excessive hypertrophy of the right ventricular wall or septum into the right ventricular outflow tract or cavity.
129
DRVO: Color flow Doppler documents the presence of turbulent flow within the RV outflow tract and spectral Doppler displays a ........-peaking flow velocity.
Color flow Doppler documents the presence of turbulent flow within the RV outflow tract and spectral Doppler displays a late-peaking flow velocity.
This is a dynamic and variable obstruction to flow
130
Frame-by-frame analysis can show septal and right ventricular free-wall ............. at the point where high velocity flow originates.
Frame-by-frame analysis can show septal and right ventricular free-wall apposition at the point where high velocity flow originates.
131
The gradients associated with this RV outflow obstruction are ....?
low with velocities ranging from 1.7 to 4.0 m/sec in cats and man
(mean and median 2.4 and 2.3 m/sec, respectively.)
Fig 7.30
132
The absence of other cardiac disease is more common in ....... cats than in ......... cats with DRVO.
The absence of other cardiac disease is more common in older cats than in young cats with DRVO.
133
Reported associations with DRVO in the cat include?
```
HCM
Chronic renal failure with or without hypertension
Hyperthyroidism
Anemia
Neoplasia
Inflammatory process
```
Hyperdynamic function especially when associated with some of the listed conditions or with increased sympathetic stimulation are hypothesized as underlying causes of DRVO
134
Moderator Bands:
False tendons or moderator bands may be a normal finding in many animals and are common in the ........ side of the heart.
False tendons or moderator bands may be a normal finding in many animals and are common in the right side of the heart.
Fig 7.31
Occasionally they may restrict LV filling.
135
Moderator band: these tendons cross the ventricular cavity connecting the ......... and .................
these tendons cross the ventricular cavity connecting the septa and free wall or papillary muscles.
136
Moderator band:
| Echo abnormalities include....?.
A rounded LV apex, irregular contours to the chamber, and a narrowed ventricular chamber
137
Moderator band: These cats may present with symptoms very similar to cats with cardiomyopathy of any form. Not all moderator bands create problems however, and the identification of a false tendon by echo should not be immediately associated with cardiac malfunction.
Moderator band: These cats may present with symptoms very similar to cats with cardiomyopathy of any form. Not all moderator bands create problems however, and the identification of a false tendon by echo should not be immediately associated with cardiac malfunction.
138
Dilated cardiomyopathy:
Idiopathic DCM is a myocardial disease of unknown etiology. In man there are some known causes of DCM including ,,,,,?
toxins like ethanol and lead, metabolic abnormalities such as nutritional and endocrine disorders, inflammatory and infectious processes, neuromuscular diseases including several dystrophies, and there is a definite familial component.
139
The cause of most DCM in animals remains unknown, but several potential underlying causes are being studied. These include?
Carnitine deficiencies
Metabolic abnormalities including hypothyroidism
Myocarditis
Taurine deficiency
140
Plasma taurine levels are not low in dogs with DCM except for possibly the Cocker Spaniel, and were actually found to be significantly higher than levels found in normal healthy dogs.
Plasma taurine levels are not low in dogs with DCM except for possibly the Cocker Spaniel, and were actually found to be significantly higher than levels found in normal healthy dogs.
141
Familial DCM is reported in which breeds?
```
Doberman Pinschers
Boxer
English Cocker Spaniels
Irish Wolfhounds
Young Portuguese water dogs
Great Danes
Newfoundlands
```
142
In Portugese water dogs, the disease strikes young puppies, and the time from clinical presentation to the development of congestive heart failure is weeks.
In Portugese water dogs, the disease strikes young puppies, and the time from clinical presentation to the development of congestive heart failure is weeks.
143
The prominent features of DCM are similar in dogs, cats, and horsed, and include?
Ventricular dilation
Atrial dilation
Normal or thin wall and septal thicknesses
Depressed systolic thickening of the wall and septum
Poor fractional shortening
Large E point to septal separation (EPSS)
Reduced aortic wall motion
Global hypokinesis
144
DCM;
2D and M-mode evaluation:
Ventricular dilation and poor function are the hallmarks of DCM. Several breeds display either a lack of dilation or extreme dilation because of the myocardial disease, and these include?
Boxer
Doberman pinscher
Dalmatian
145
The Dalmatian appears to exhibit more ............... than any breed with DCM
The Dalmatian appears to exhibit more ventricular and atrial dilation than any breed with DCM
146
Boxer DCM: may have .......ventricular chamber size despite poor LV systolic function.
: may have normal ventricular chamber size despite poor LV systolic function.
147
Dobermans tend to display less right-sided involvement than other breeds with DCM. LV diastolic dimensions > .......cm and systolic LV dimensions > ...... cm with FS of
LV diastolic dimensions > 4.6 cm and systolic LV dimensions > 3.8 cm with FS of
148
It is important to remember that FS alone should not be used as the defining criteria for the diagnosis of DCM.
FS is .......... and ............. dependent, and transient depressions in this parameter can occur normally.
FS is preload and afterload dependent, and transient depressions in this parameter can occur normally.
149
Increases chamber size and increased ............ combined with poor fractional shortening are usually indicative of the presence of DCM.
Increases chamber size and increased EPSS combined with poor fractional shortening are usually indicative of the presence of DCM.
Serial studies are often necessary before the diagnosis can be made with certainty
150
DCM: features?
```
Dilated LV: some breeds do not show this
Atrial dilation
Normal to thin LVW and VS
Poor fractional shortening
Large EPSS
```
151
Early DCM may exhibit only increased ............... LV dimensions and normal ..............dimensions as fractional shortening decreases.
Early DCM may exhibit only increased systolic LV dimensions and normal diastolic dimensions as fractional shortening decreases.
Diastolic chamber size will increase as function deteriorates and forward flow is compromised.
152
One study in cats with taruine deficiency showed only increased systolic LV dimensions and decreased fractional shortening with no dilatin of the ventricle during diastole. Another study however, did show LV dilation.
One study in cats with taruine deficiency showed only increased systolic LV dimensions and decreased fractional shortening with no dilatin of the ventricle during diastole. Another study however, did show LV dilation.
153
LA and sometimes RA dilation develop as myocardial failure progresses. Elevated LV end systolic pressure creates less of a pressure gradient from the atrium into the ventricle resulting in ......... atrial emptying, high LA pressures, and atrial dilation.
LA and sometimes RA dilation develop as myocardial failure progresses. Elevated LV end systolic pressure creates less of a pressure gradient from the atrium into the ventricle resulting in less atrial emptying, high LA pressures, and atrial dilation.
154
DCM: Some cats display normal LA size on echo examinations but do have parameters that are at the high end of the normal range. Echo evidence of atrial enlargement may be present before there is radiographic indication of atrial dilation.
As with HCM, a thrombus may form within the LA or auricular chamber.
Some cats display normal LA size on echo examinations but do have parameters that are at the high end of the normal range. Echo evidence of atrial enlargement may be present before there is radiographic indication of atrial dilation.
As with HCM, a thrombus may form within the LA or auricular chamber.
Fig 7.34
155
Septal and free wall thicknesses may be normal but are typically thin. There is no measurable hypertrophy even though heart size and weight are increased.
Septal and free wall thicknesses may be normal but are typically thin. There is no measurable hypertrophy even though heart size and weight are increased.
156
DCM: A decrease in wall thickness to chamber size ratio implies ..........?
A decrease in wall thickness to chamber size ratio implies inadequate hypertrophy and myocardial abnormalities.
Prognosis i poorer in human patients with low ratios.
157
DCM: The wall and septum also have reduced ............ thickening and excursions as myocardial function deteriorates.
The wall and septum also have reduced systolic thickening and excursions as myocardial function deteriorates.
158
DCM: The lack of compensatory hypertrophy as the ventricle dilates increases LV ............. and wall .................... further decreasing fractional shortening and velocity of circumference shortening.
The lack of compensatory hypertrophy as the ventricle dilates increases LV afterload and wall stress further decreasing fractional shortening and velocity of circumference shortening.
159
In Irish Wolfhounds with DCM and normal thickness, there is reduced ..................thickening.
In Irish Wolfhounds with DCM and normal thickness, there is reduced systolic thickening.
160
The E point to septal separation (EPSS) is always ............. in dogs and cats with DCM
The E point to septal separation (EPSS) is always increased in dogs and cats with DCM: Fig 4.38
161
DCM: The degree of mitral valve motion toward the inter ventricular septum is dependent upon flow from the atrium into the ventricle. As end systolic remains large secondary to poor contraction, elevated LV filling ........... limits the amount of blood flowing from the atrium into the ventricle.
The degree of mitral valve motion toward the inter ventricular septum is dependent upon flow from the atrium into the ventricle. As end systolic remains large secondary to poor contraction, elevated LV filling pressure limits the amount of blood flowing from the atrium into the ventricle.
162
DCM: As end systolic remains large secondary to poor contraction, elevated LV filling pressure limits the amount of blood flowing from the atrium into the ventricle.
Mitral excursion is ............ as a result and EPSS .............. This is a sensitive and specific sign of early DCM even in asymptomatic dogs and in dogs with equivocal values for all other parameters of size and function.
Mitral excursion is reduced as a result and EPSS increases. This is a sensitive and specific sign of early DCM even in asymptomatic dogs and in dogs with equivocal values for all other parameters of size and function.
163
Mitral excursion is reduced as a result and EPSS increases.
The EPSS in Doberman Pinchers shows ............ between Doberman's with normal function and those with occult DCM, making it an important factor in the assessment of DCM in this breed.
The EPSS in Doberman Pinchers shows no overlap between Doberman's with normal function and those with occult DCM, making it an important factor in the assessment of DCM in this breed.
There is overlap in EPSS measurements between normal Irish Wolfhounds and Irish Wolfhounds with DCM however.
164
A "B" bump at the end of mitral valve diastolic motion signifying ................ is a sign of increased end diastolic LV pressures.
A "B" bump at the end of mitral valve diastolic motion signifying delayed closure is a sign of increased end diastolic LV pressures.
This may or may ot be found in dogs with DCM.
Fig 4.99, 5.24
it has routinely only been seen in dogs with severe CHF.
165
Parameters of systolic function are always altered in DCM.
FS, ejection time, and Vcf are ........... while pre-ejection period (PEP) is ................
Parameters of systolic function are always altered in DCM.
FS, ejection time, and Vcf are decreased while pre-ejection period (PEP) is increased. Fig 7.36
166
The ratio of PEP to LV ejection time (LVET) is ................ in DCM secondary to slow rate of pressure rise during isovolumic contraction.
The ratio of PEP to LV ejection time (LVET) is increased in DCM secondary to slow rate of pressure rise during isovolumic contraction.
This value is not sensitive however, as PEP/LVET ratios may still be normal in dogs with overt heart signs of heart failure.
167
LVET does not appear to be affected on a consistent basis in cats treated for DCM. These values although still abnormal after the initiated of therapy, improve and move toward the normal range.
LVET does not appear to be affected on a consistent basis in cats treated for DCM. These values although still abnormal after the initiated of therapy, improve and move toward the normal range.
168
Even when LVET is normal, gradual closure of the ...............valve may be seen as ventricular systolic pressures decline throughout systole and forward flow declines.
Even when LVET is normal, gradual closure of the aortic valve may be seen as ventricular systolic pressures decline throughout systole and forward flow declines. Fig 4.95
169
The total systolic time, QAVC, measured from the onset of the .......... to closure of the ............valve, is increased in cats with systolic dysfunction and DCM.
The total systolic time, QAVC, measured from the onset of the QRS complex to closure of the aortic valve, is increased in cats with systolic dysfunction and DCM.
170
The QAVC parameter consistently reflects increases in systolic function as cats with DCM are treated with ..........drugs.
The QAVC parameter consistently reflects increases in systolic function as cats with DCM are treated with inotropic drugs.
171
Mitral annular motion (MAM) of the septal mitral annulus obtained from apical 4 ch views reflects long-axis ............ function.
Mitral annular motion (MAM) of the septal mitral annulus obtained from apical 4 ch views reflects long-axis systolic function.
172
Dogs with DCM have significantly ............ MAM, MAM% and MAM index.
Dogs with DCM have significantly decreased MAM, MAM% and MAM index. Fig 7.37
173
Normal MAM is 0.46-1.74 cm while dogs with DCM have MAM ranging from 0.27-1.06 mm.
Normal MAM is 0.46-1.74 cm while dogs with DCM have MAM ranging from 0.27-1.06 mm.
174
The MAM%, a reflection of the contribution of annular motion to the overall ventricular long-axis shortening, is 31-45% in normal dogs and 32-89% in dogs with DCM.
The MAM%, a reflection of the contribution of annular motion to the overall ventricular long-axis shortening, is 31-45% in normal dogs and 32-89% in dogs with DCM.
175
MAM indexed to BSA separates normal from abnormal dogs as well.
MAM indexed to BSA separates normal from abnormal dogs as well.
MAM index i s0.78-3.78 cm/m upphöjt i 2 in normal canine hearts and 0.16-1.27 in dogs with DCM
176
Mitral annular motion may be useful for early detection of DCM in hearts where longitudinal shortening may be affected before radial shortening is affected.
Mitral annular motion may be useful for early detection of DCM in hearts where longitudinal shortening may be affected before radial shortening is affected.
177
Early diagnosis:
Early DCM is a challenge to diagnosis. The first signs of DCM may be cardiac arrhythmias, which include?
VPCS
VT
Supraventr tachycardia
Brady-arrhythmias
Echo exam in these animals typically reveal normal cardiac dimensions but very mild to moderately depressed FS.
178
Diastolic LV chamber size of > ....... mm, or a systolic chamber size >....... mm, or even one VPC suggests occult DCM in Doberman Pinschers.
Diastolic LV chamber size of > 46 mm, or a systolic chamber size > 38 mm, or even one VPC suggests occult DCM in Doberman Pinschers.
179
The interpretation of ventricular dilation and poor FS is sometimes difficult, especially when breed-specific echo reference ranges do not exist.
The progression of the disease is slow in most cases, and heart failure may not manifest itself for several years.
The interpretation of ventricular dilation and poor FS is sometimes difficult, especially when breed-specific echo reference ranges do not exist.
The progression of the disease is slow in most cases, and heart failure may not manifest itself for several years.
180
LV chamber size will increase over the years as FS continues to deteriorate.
LV chamber size will increase over the years as FS continues to deteriorate.
Repeat echo exams are usually necessary to verify the diagnosis of DCM when subclinical disease exists.
181
Poor FS:
Rule out poor ......... as a cause
Rule out increased ........... as a cause.
Rule out poor preload as a cause
| Rule out increased afterload as a cause.
182
The European Society of veterinary cardiology has established criteria for the early diagnosis of DCM in the preclinical phase. A point system is used, and applied to various echo and electrocardiographic parameters. 6 points or greater is highly suggestive of the presence of subclinical DCM.
The European Society of veterinary cardiology has established criteria for the early diagnosis of DCM in the preclinical phase. A point system is used, and applied to various echo and electrocardiographic parameters. 6 points or greater is highly suggestive of the presence of subclinical DCM.
183
Major criterial worth 3 points include?
```
-LV dilation in systole or diastole
Increased sphericity (
```
184
Minor criteria worth 1 point include?
- Arrhyhtmia in Boxers and Dobermans
- Atrial fibrillation, increased EPSS, pre-ejection period to ejection time ratio > 0.4 (PEP/LVET), FS in the equivocal range (>20-25%, but less than 30%)
- Left atrial or biatrial dilation.
185
Other causes of myocardial failure should be ruled out before the diagnosis of familial or idiopathic DCM is made. These criteria are listed in Table 7.4
Other causes of myocardial failure should be ruled out before the diagnosis of familial or idiopathic DCM is made. These criteria are listed in Table 7.4
186
Sphericity is assessed by comparing LV .......... obtained from a 4 ch view to the ............. measurement of diastolic dimension.
Sphericity is assessed by comparing LV length obtained from a 4 ch view to the M-mode measurement of diastolic dimension. Fig 7.38
187
Normal sphericity is ...?
1.78 +/-0.16
188
Dilation develops and the chamber becomes more spherical as the ventricular chamber becomes dysfunctional.
Dilation develops and the chamber becomes more spherical as the ventricular chamber becomes dysfunctional.
189
Even using the European point system may lead to equivocal results. Reevaluation is often necessary and where there is no increase in ventricular chamber size or decree in FS on subsequent echo exams, it indicates .......
...that the equivocal parameters of size and function may be normal for the specific animal.
190
Subclinical DCM.
| Using the European point system may help identify:
6 points highly suggestive of subclinical DCM
191
Value of TDI in DCM dogs?
May be helpful in the early identification of dogs with DCM.
192
Using right parasternal transverse images of the LV chamber at the level of the papillary muscles, PW color-tissue Doppler of radial motion shows .............. endocardial systolic and diastolic velocities when compared to epicardial velocity.
Using right parasternal transverse images of the LV chamber at the level of the papillary muscles, PW color-tissue Doppler of radial motion shows decreased endocardial systolic and diastolic velocities when compared to epicardial velocity.
193
A gradient is seen in dogs without heart disease, but the endocardial velocities in systole (Se´) and both phases of diastole (E´, A´) in dogs with subclinical DCM is lower. Fig 7.39
A gradient is seen in dogs without heart disease, but the endocardial velocities in systole (Se´) and both phases of diastole (E´, A´) in dogs with subclinical DCM is lower.
194
Radial epicardial velocities in systole and diastole ...........different between normal dogs and dogs with subclinical DCM:
Radial epicardial velocities in systole and diastole are not different between normal dogs and dogs with subclinical DCM: This results in decreased radial trans myocardial velocity gradients (the difference between endocardial and epicardial velocities) during systole and early diastole.
195
Longitudinal myocardial velocities of the LV free wall from apical 4 ch views although still higher at the base than the apex as in normal dogs, are ....................at the base in systole and early diastole in dogs with subclinical DCM.
The resulting longitudinal myocardial gradient (difference between ............... myocardial velocity) is ............... in systole and early diastole in dogs with pre-clinical DCM.
Longitudinal myocardial velocities of the LV free wall from apical 4 ch views although still higher at the base than the apex as in normal dogs, are reduced at the base in systole and early diastole in dogs with subclinical DCM.
The resulting longitudinal myocardial gradient (difference between basal and apical myocardial velocity) is reduced in systole and early diastole in dogs with pre-clinical DCM.
Fig 7.40
196
Late diastolic radial and longitudinal myocardial gradients are ............ in the preclinical setting.
Late diastolic radial and longitudinal myocardial gradients are not affected in the preclinical setting.
197
The E´-A´ration of radial and longitudinal myocardial velocities is alos .............in subclinical DCM.
The E´-A´ration of radial and longitudinal myocardial velocities is alos decreased in subclinical DCM.
198
TDI and subclincial DCM:
| ........... epicardial to endocardial radial gradient.
Decreased epicardial to endocardial radial gradient.
199
TDI and subclincial DCM:
| ............... basal to apical longitudinal gradient.
Decreased basal to apical longitudinal gradient.
200
DCM: Predictors of outcome:
The clinical course of these animals is extremely variable, and the degree of ventricular dilation, the EPSS or FS has no predictive value for survival time.
The clinical course of these animals is extremely variable, and the degree of ventricular dilation, the EPSS or FS has no predictive value for survival time.
201
Although 50% of dogs in one study survived past 3 months, M-mode echo parameters could not predict which dogs would be long-term survivors and which would not.
Although 50% of dogs in one study survived past 3 months, M-mode echo parameters could not predict which dogs would be long-term survivors and which would not.
In those studies, only the presence of pleural effusion, pulmonary edema, ascites, or a young age at diagnosis was found to suggest poorer survival times.
202
Measurement of ........... using the area length method on apical or right parasternal 2D
four chamber imaging planes is a predictor of outcome and survival time.
Measurement of ejection fraction using the area length method on apical or right parasternal 2D
four chamber imaging planes is a predictor of outcome and survival time.
Fig 7.41
An ejection fraction
203
Calculation of the ............volume index from M-mode using the Teicholz equation and the dog's body surface area is also predictive of survival time. Fig 7.42
Calculation of the systolic volume index from M-mode using the Teicholz equation and the dog's body surface area is also predictive of survival time. Fig 7.42
Dogs with a systolic volume index > 140 ml/m2 have a median survival time of 208 days.
204
Elevated LA pressure affects transmitral valve flow into LV chamber. When the increased LV filling pressure results in a restrictive inflow pattern with a ......... E wave, .......... early deceleration and a ....... A wave, it is associated with poor survival in dogs and in man with DCM.
When the increased LV filling pressure results in a restrictive inflow pattern with a high E wave, rapid early deceleration and a lower A wave, it is associated with poor survival in dogs and in man with DCM.
205
Rapid transmitral E wave deceleration time of
A transmitral E wave deceleration time of
206
The presence of pulmonary hypertension and concomitant poor RV function is associated with a poorer prognosis for human patients with DCM
The presence of pulmonary hypertension and concomitant poor RV function is associated with a poorer prognosis for human patients with DCM.
In man, tricuspid annular motion of less than 1.25 cm is independent predictor of poor survival.
207
There is currently no report of prognostic indicators for survival time since the advent of pimobendan therapy. The prognostic value of these parameters may be altered as more info is gathered in dogs receiving pimobendan.
There is currently no report of prognostic indicators for survival time since the advent of pimobendan therapy. The prognostic value of these parameters may be altered as more info is gathered in dogs receiving pimobendan.
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Other causes of poor systolic function:
When taurine deficiency is thought be be the underlying cause of DCM in cats, improvement in cardiac size and function occurs anywhere from .................... after supplementation.
When taurine deficiency is thought be be the underlying cause of DCM in cats, improvement in cardiac size and function occurs anywhere from 3 to 16 weeks after supplementation.
These cats had essentially normal echocardiograms 6 months to 1 year after initial presentation.
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The usually reversible ..................dysfunction found in dogs with hypothyroidism does not manifest itself with any significant dilation of the LV chamber during ...................
The usually reversible systolic dysfunction found in dogs with hypothyroidism does not manifest itself with any significant dilation of the LV chamber during diastole.
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Echo features in these hypothyroid dogs include?
Increased systolic dimensions
Decreased FS
Decreased Vcf
Increased PEP
Dogs with hypothyroidism and impaired function do not typically show signs of show signs of heart failure unless pre-existing myocardial failure exists.
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Sepsis can cause reversible myocardial failure and has been reported in the dog. Findings include?
Dilation
Decreased FS
Secodnary MR
Large end systolic volume indices
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Myocardial dysfunction is seen in 40-50% of people with sepsis. Myocardial depression is thought to be secondary to circulating myocardial depressant factors, nitric oxide, tissue hypoxia, reperfusion injury, and increased circulating catecholamines.
Myocardial dysfunction is seen in 40-50% of people with sepsis. Myocardial depression is thought to be secondary to circulating myocardial depressant factors, nitric oxide, tissue hypoxia, reperfusion injury, and increased circulating catecholamines.
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Cancer treatment with doxorubicin is a documented cause of DCM. There is early depression in systolic function that occurs within the first few days. This is .............. With cumulative doses however, there are .............. changes in systolic function.
Cancer treatment with doxorubicin is a documented cause of DCM. There is early depression in systolic function that occurs within the first few days. This is reversible. With cumulative doses however, there are irreversible changes in systolic function.
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Echo changes in dogs treated with doxorubicin include?
diastolic dysfunction early in the course of myocardial function
Doppler echo shows increased isovolumic relaxation times and decreased early LV filling.
Global systolic failure occurs later.
LV dilation is present is mild, a feature that differentiate it from idiopathic DCM and most other cause of left-sided CHF.
The septum in man is usually more affected than the rest of the left ventricle.
215
Color Doppler evaluation:
MR is common in animals with DCM secondary to dilation of the mitral annulus. The insufficiency varies from mild to severe when present and contributes to the clinical signs of CHF. Valvular lesions will not be evident if the insufficiency is truly secondary to the dilation.
Color Doppler evaluation:
MR is common in animals with DCM secondary to dilation of the mitral annulus. The insufficiency varies from mild to severe when present and contributes to the clinical signs of CHF. valvular lesions will not be evident if the insufficiency is truly secondary to the dilation.
216
Spectral Doppler evaluation:
Systolic function:
Maximal aortic flow velcoity is typically ........... in animals with DCM.
```
Maximal aortic flow velcoity is typically reduced in animals with DCM. Fig 7.44
Aortic flow velocities that remain within the normal range suggest maintenance of adequate cardiac output.
Acceleration rate (dv/dt) may be a better indicator, but there is tremendous variation in this parameter in both healthy and DCM dogs.
```
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Spectral Doppler evaluation:
Diastolic function:
Diastolic dysfunction may have a more significant impact on clinical signs than systolic failure. People and dogs with extremely poor systolic function often do not show significant clinical symptoms.
The progression of occult to overt DCM may develop as ventricular filling is altered causing ..............
The progression of occult to overt DCM may develop as ventricular filling is altered causing LA dilation and elevated LA pressure.
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table 7.5 summarizes the diastolic parameters that change in the presence of DCM
table 7.5 summarizes the diastolic parameters that change in the presence of DCM
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Mitral inflow studies in dogs with overt DCM show .......... E wave velocity, .............. A wave velocity, ............. E wave duration, and ............. E:A ratio and ............. E wave deceleration time.
Mitral inflow studies in dogs with overt DCM show increased E wave velocity, no change in A wave velocity, increased E wave duration , and increased E:A ratio and decreased E wave deceleration time.
Figures 4.75, 7.45.
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Dogs with occult DCM have variable and inconsistent transmitral flow patterns probably reflecting ................
Dogs with occult DCM have variable and inconsistent transmitral flow patterns probably reflecting different stages of disease progression
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The presence of moderate to severe mitral insufficiency will aslo increase .......... velocity and must be considered when evaluating diastolic function and atrial pressures.
The presence of moderate to severe mitral insufficiency will aslo increase E velocity and must be considered when evaluating diastolic function and atrial pressures.
Fig 4.81
222
Changes in the mitral inflow profile in man are closely correlated with the improvement or deterioration of clinical status.
An increase in E:A ratio signified ............. of clinical status while decrease in E:A ratio is observed .............................
An increase in E:A ratio signified deterioration of clinical status while decrease in E:A ratio is observed as signs of heart failure resolve.
These changes correlated to changes in capillary wedge pressure.
223
Rapid................. times (
Rapid deceleration times (
224
Doppler evaluation of transmitral flow appears to be the best predictor of survival time in dogs at this point.
A ............... transmitral flow patterns (E:A ratio > 2.0) and a rapid early diastolic ............. (
A restrictive transmitral flow patterns (E:A ratio > 2.0) and a rapid early diastolic deceleration (
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A restrictive filling pattern represents high .......... pressure and a rapid equilibration of ventricular and atrial pressure in the presence of reduced .......... compliance.
A restrictive filling pattern represents high LA pressure and a rapid equilibration of ventricular and atrial pressure in the presence of reduced LV compliance.
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Diastolic pulmonary venous flow velocity in Doberman Pinchers with DCM is decreased. This occurs secondary to .........
An S:D ratio greater than ...... will be seen.
impaired relaxation, a sower decline in LV pressure, and a slower rate of LA emptying.
An S:D ratio greater than 1.0 will be seen.
227
Decreased compliance is seen in later stages of this disease. Systolic pulmonary venous flow becomes low as LA pressure remains high during this phase of the cardiac cycle.
Decreased compliance is seen in later stages of this disease. Systolic pulmonary venous flow becomes low as LA pressure remains high during this phase of the cardiac cycle.
228
Diastolic flow becomes more ......... as flow into the ventricle is enhanced with the elevated LA pressure and passive flow into the LA via the veins is enhanced. This S:D ratio becomes less than .........
Diastolic flow becomes more predominant as flow into the ventricle is enhanced with the elevated LA pressure and passive flow into the LA via the veins is enhanced. This S:D ratio becomes less than 1.0.
229
Velocity and duration of reverse diastolic flow (pulmonary vein A wave) late in diastole are both increased in man, but this has been difficult to show in dogs due to technical difficulties in obtaining these flow profiles.
Velocity and duration of reverse diastolic flow (pulmonary vein A wave) late in diastole are both increased in man, but this has been difficult to show in dogs due to technical difficulties in obtaining these flow profiles.
230
Isovolumic relaxation time in dogs with overt DCM and in some dogs with subclinical DCM is shorter than normal. This is because?
Because increased LA pressure causes the mitral valve to open sooner aborting the relaxation time period. This is consistent with restrictive physiology as the disease progresses.
231
PW tissue Doppler evaluation of systolic myocardial motion at the LV free wall mitral annular level shows ................ velocity from normal. Dobermans with overt cardiomyopathy have ............... Sm velocity than those with occult DCM. This is a relatively early predictor in man for the presence of DCM, but has only been reported in one canine study to date.
PW tissue Doppler evaluation of systolic myocardial motion at the LV free wall mitral annular level shows reduced velocity from normal. Dobermans with overt cardiomyopathy have lower Sm velocity than those with occult DCM. This is a relatively early predictor in man for the presence of DCM, but has only been reported in one canine study to date.
232
Early diastolic myocardial motion is reduced in some Dobermans with overt cardiomyopathy but is a consistent pattern in humans with DCM. The Doberman population was small and further study is warranted.
Early diastolic myocardial motion is reduced in some Dobermans with overt cardiomyopathy but is a consistent pattern in humans with DCM. The Doberman population was small and further study is warranted.
233
The S´velocity was consistently decreased in dogs with overt DCM. This is a reflection of?
Decreased compliance and restrictive physiology.
234
A´ velocity decreased progressively from occult to overt diseases.
A´ velocity decreased progressively from occult to overt diseases.
235
TDI and DCM
PW:
- S´........... at lateral mitral annulus
- E´may be ................
PW:
- S´ decreased at lateral mitral annulus
- E´may be decreased
236
Color TDI
- ............... radial and longitudinal gradients
- Perhaps ............... between wall and septum.
- Reduced radial and longitudinal gradients
| - Perhaps dyssynchrony between wall and septum.
237
Color-tissue Doppler studies in Golden retrievers with muscular dystrophy dilated cardiomyopathy show .............radial endocardial systolic and diastolic velocities.
Epicardial velocity did not change resulting in .............trans-myocardial velocity gradients in these dogs with DCM.
decreased radial endocardial systolic and diastolic velocities.
Epicardial velocity did not change resulting in decreased trans-myocardial velocity gradients in these dogs with DCM.
Longitudinal velocity of the LV free wall was decreased at the annulus in systole and diastole, also resulting in a decreased gradient between the base and the apex.
238
Dogs with DCM have a strong negative relationship between the timing of systolic color-tissue Doppler motion with respect to the beginning of electrical systole and ejection fraction. The parameters are heart rate corrected by dividing each parameter by the square root of the R-R interval.
Dogs with DCM have a strong negative relationship between the timing of systolic color-tissue Doppler motion with respect to the beginning of electrical systole and ejection fraction. The parameters are heart rate corrected by dividing each parameter by the square root of the R-R interval.
239
Heart rate corrected parameters that are longer in dogs with DCM and that are negatively correlated with EF include the times from Q to start S´, Q to end S´at the base of both the LV free wall and septum. These changes are consistent with delays in longitudinal shortening of the LV myocardium in DCM
Heart rate corrected parameters that are longer in dogs with DCM and that are negatively correlated with EF include the times from Q to start S´, Q to end S´at the base of both the LV free wall and septum. These changes are consistent with delays in longitudinal shortening of the LV myocardium in DCM
240
There is also a significant positive correlation between S´ velocity at the base of the free wall and the EF. Peak velocity is .................. in dogs with DCM and may be an early indicator of disease.
There is also a significant positive correlation between S´ velocity at the base of the free wall and the EF. Peak velocity is depressed in dogs with DCM and may be an early indicator of disease.
Breed variations exist and tis parameter needs further study in various breeds.
241
The myocardial performance index has been studied in Newfoundlands with DCM. Using PW Doppler of mitral closure to opening time and LV ejection time, this study found ........... pre-ejection periods, ............ ejection time, and ............ isovolumic relaxation and contraction time periods, with resultant significantly increased Tei index in dogs with overt DCM.
increased pre-ejection periods, shortened ejection time, and increased isovolumic relaxation and contraction time periods, with resultant significantly increased Tei index in dogs with overt DCM.
Normal newfoundlands had Tei index of 0.28 +/- 0.12 while dogs with DCM had a Teid index of 0.51 +/- 0.32
This parameter does not show any more specificity in differenting normal from abnormal function, and it cannot reliably differentiate subclinical from normal hearts.
Diastolic dysfunction with restrictive physiology is only present in the these dogs with more advanced stages of DCM.
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RV dilated cardiomyopathy: An infiltrative disease involving fatty and fibrous replacement of myocyte after presumed cell death occurs. This entity is also called?
Right ventricular dysplasia
243
RV dilated cardiomyopathy: The left side of the heart echocardiographically may appear normal even though histologically changes may be present. How is the right side?
There is severe right ventricular and atrial dilation with poor RV systolic function and paradoxical septal motion secondary to the elevated right-sided diastolic pressures.
244
RV dilated cardiomyopathy: Other signs of right-sided heart failure like ......?
pleural effusion and pericardial effusion may be seen both radiographically and echocardiographically.
There may be TR and if present, spectral Doppler should be used to rule out pulmonary hypertension as a cause of the right-sided heart failure instead of cardiomyopathy.
245
RV dilated cardiomyopathy: The foramen oval may become .................when right atrial pressure become excessive.
RV dilated cardiomyopathy: The foramen oval may become patent when right atrial pressure become excessive.
246
In man, RV cardiomyopathy is associated with highly irregular endocardial surfaces with prominent bulges and deep fissures.
In man, RV cardiomyopathy is associated with highly irregular endocardial surfaces with prominent bulges and deep fissures.
247
RV dilated cardiomyopathy: An
arrhythmogenic form of this cardiomyopathy is reported in cats. Significant dilation of the RV and atrium with systolic dysfunction and arrhythmia (..........................(3) are seen in these cats that present in right-sided congestive heart failure.
Significant dilation of the RV and atrium with systolic dysfunction and arrhythmia (ventricular tachyarrhythmia, atrioventricular block, atrial fibrillation) are seen in these cats that present in right-sided congestive heart failure.
248
Arrhythmogenic right ventricular cardiomyopathy is reported in dogs, and Boxers have a predisposition to developing the RV ventricular arrhythmias sometimes without echo evidence of abnormal myocardium or function
Arrhythmogenic right ventricular cardiomyopathy is reported in dogs, and Boxers have a predisposition to developing the RV ventricular arrhythmias sometimes without echo evidence of abnormal myocardium or function
249
Features of RV cardiomyopathy?
RV dilation
RA dilation
Paradoxical septal motion
Irregular endocardial surface
250
Restrictive cardiomyopathy (RCM) found primarily in the cat, is poorly characterized and is sometimes called?
Intermediate, intergrade, or unclassified cardiomyopathy.
RCM is the preferred term however, and intermediate cardiomyopathy should be resered for cases where the features of more than one type of cardiomypathy exists and differentiation is not possible
251
Primary RCM is typically idiopathic with predominant diastolic failure secondary to infiltrative fibrosis of the myocardium.
Primary RCM is typically idiopathic with predominant diastolic failure secondary to infiltrative fibrosis of the myocardium.
252
A less common form of RCM is endomyocardial fibrosis, an obliterative process.
A less common form of RCM is endomyocardial fibrosis, an obliterative process.
253
Secondary processes that may result in restrictive physiology include?
Amyloid heart disease
Hypertension
HCM
DCM
254
Restrictive physiology is characterized by?
Reduced ventricular compliance where compliance where diastolic filling is completed early in the diastolic time period.
255
2D evaluation:
Myocardial restrictive cardiomyopathy typically involves ................ LV chamber size and wall thicknesses with significant LA ..............
Myocardial restrictive cardiomyopathy typically involves normal to near normal LV chamber size and wall thicknesses with significant LA dilation
256
Echo features are not well documented nor does RCM have uniformly accepted diagnostic criteria. Moderate to severe ......... enlargement is one consistently requires criteria for RCM however.
Moderate to severe LA enlargement is one consistently requires criteria for RCM however.
257
RCM: Atrial enlargement may be seen only on the left, but typically both atria are involved. Atrial dilation occurs secondary to?
Atrial dilation occurs secondary to high LV filling pressure and reduced ventricular compliance.
258
RCM: Mitral insufficiency?
Often there is no regurgitation at all, but there might be mild MR.
259
RCM: At times a thrombus is seen within the LA or auricular cavity, more often however the smoke-like echoes (spontaneous echo contrast) of sluggish blood may be seen within the atrial chamber.
At times a thrombus is seen within the LA or auricular cavity, more often however the smoke-like echoes (spontaneous echo contrast) of sluggish blood may be seen within the atrial chamber.
Fig 7.26, 7.47
260
RCM features? (4)
- LA dilation; usually severe. Often with only mild MR
- Hypertrophy only mild of present
- Increased echogenicity in areas of myocardium (fibrosis)
- Function normal early, coming depressed as fibrosis develops
261
RCM: Hypertrophy if present is?
Mild.
262
RCM: LV charactersitics?
LV chamber size is usually normal but may be slightly increased.
263
RCM: The endocardial surface is?
Irregular with areas of the septum or free wall that are visibly thicker than other areas,
There may be echogenic areas within the myocardium representing fibrosis, but this is not a consistent finding. Fig 7.48
264
One uncommon form of RCM involves endomyocardial scarring with connections between the septum and LV wall.
There may be .................. obstruction associated with this form of the disease as the fibrotic muscle becomes obliterative.
There is usually .............. of the chordae and the papillary muscles resulting in mitral regurgitation. There may be evidence of myocardial infarction and involvement of the right side of the heart.
One uncommon form of RCM involves endomyocardial scarring with connections between the septum and LV wall.
There may be mid ventricular obstruction associated with this form of the disease as the fibrotic muscle becomes obliterative.
There is usually fibrosis of the chordae and the papillary muscles resulting in mitral regurgitation. There may be evidence of myocardial infarction and involvement of the right side of the heart.
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RCM: When cats decompensate, right-sided heart changes become evident on the echo exam. These signs include...................?
When cats decompensate, right-sided heart changes become evident on the echo exam. These signs include RV dilation with hypertrophy and pleural and pericardial effusions.
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RCM: Evaluation of function: Systolic LV function in RCM is normal to mildly depressed with FS above 22%. There may be areas of hypokinesis or dyskinesia associated with the myocardial fibrosis. ...............dysfunction is the predominant feature of RCM
Diastolic dysfunction is the predominant feature of RCM
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RCM: Doppler evaluation of mitral inflow may show ............. E velocity, .............. early deceleration, and little if any filling ................. in diastole resulting in reduced or absent atrial filling component on the inflow profile.
Doppler evaluation of mitral inflow may show increased E velocity, rapid early deceleration, and little if any filling late in diastole resulting in reduced or absent atrial filling component on the inflow profile.
Fig 4.75, 7.49
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Early RCM may not show the restrictive pattern of filling but instead shows evidence of impaired .............. This mitral inflow patterns shows reduced early filling with a strong atrial component to filling resulting in an E:A ratio ................
impaired relaxation
This mitral inflow patterns shows reduced early filling with a strong atrial component to filling resulting in an E:A ratio less than 1.
In the cat, this is a very difficult pattern to record. Heart rates are usually too rapid to differentiate the 2 phases of LV filling.
269
Diastolic dysfunction and RCM:
Poor compliance.
PW spectral Doppler shows:
Increased transmitral E wave
Reduced or absent transmitral A wave
Short IVRT
270
Diastolic dysfunction and RCM:
Poor compliance.
Tissue Doppler shows:
Increased E´ at mitral annulus
271
Tissue Doppler imaging in cats with RCM shows increased ............... velocity at the mitral annulus on apical 4 ch views and on the LV wall on right parasternal transverse views at the level of the ......................muscles.
Acceleration and deceleration rates are ................. at both locations.
Tissue Doppler imaging in cats with RCM shows increased diastolic velocity at the mitral annulus on apical 4 ch views and on the LV wall on right parasternal transverse views at the level of the papillary muscles.
Acceleration and deceleration rates are increased at both locations.
A study showed a subgroup of cats with unclassified cardiomyopathy with tissue Doppler velocity that were no different from tissue velocities in cats with hypertrophic cardiomyopathy.
272
Differentiation of RCM from other disease: often difficult. The 2 most common differentials?
HCM and constrictive pericarditis.
273
Constricitve pericarditits is associated with .............. variation in peak mitral and tricuspid inflow velocities, pulmonary venous flow, and isovolumic relaxation times.
Constricitve pericarditits is associated with respiratory variation in peak mitral and tricuspid inflow velocities, pulmonary venous flow, and isovolumic relaxation times. RCM does not show this respiration variation.
274
HCM may show the restrictive inflow pattern associated with RCM. In man when restrictive obstruction physiology is present in the absence of outflow obstruction and only mild to moderate myocardial hypertrophy as well as a disproportionately large atrium compared to ventricular changes are present, then the diagnosis of ............ is made versus ..........
HCM may show the restrictive inflow pattern associated with RCM. In man when restrictive obstruction physiology is present in the absence of outflow obstruction and only mild to moderate myocardial hypertrophy as well as a disproportionately large atrium compared to ventricular changes are present, then the diagnosis of RCM is made versus HCM.
It is a challenge to differentiate, but the therapeutic approach is often the same, and so the distinction is often not critical.
275
Endocardial fibroelastosis:
| Endocardial fibrosis in the dog has been described and features include?
- A dilated LV chamber with decreased wall and septal motion
- Depressed fractional shortening
- Dilated LA and auricle
- Abnormal mitral valve morphology and motion
276
Endocardial fibroelastosis:
Necropsy findings showed extensive endocardial and myocardial fibrosis with variable areas of hypertrophy. The mitral apparatus us involved in this disease process with ...............
Necropsy findings showed extensive endocardial and myocardial fibrosis with variable areas of hypertrophy. The mitral apparatus us involved in this disease process with thickening of the leaflets and chordae.
277
Endocardial fibroelastosis: The disease is differentiated from degenerative mitral valve disease by .........
by the excellent systolic function present in most hearts with mitral insufficiency secondary to endocardiosis.
This disease is only reported in young dogs, and its status as an acquired defects is debatable.
278
Arrhythmogenic right ventricular cardiomyopathy:
An infiltrative disease of the right ventricular myocardium. Fatty and fibrous infiltration leads to ventricular and supraventricular arrhythmias that often result in sudden death. The infiltrative process may involve the LV chamber in some cases.
An infiltrative disease of the right ventricular myocardium. Fatty and fibrous infiltration leads to ventricular and supraventricular arrhythmias that often result in sudden death. The infiltrative process may involve the LV chamber in some cases.
279
Arrhythmogenic right ventricular cardiomyopathy: The disease is reported in cats with echo manifestations that include ....?
Pronounced right atrial and ventricular dilation, paradoxical septal motion, abnormal trabeculation of the right ventricular wall, and aneurysmal dilation of the right ventricular wall with akinetic and dyskinetic muscle.
280
Arrhythmogenic right ventricular cardiomyopathy: The left side of the heart is essential normal. Abnormalities of the left side when present include?
- Atrial dilation: The LA dilation ranges from mild to severe in these cats.
- Abnormal fractional shortening in the presence of paradoxical septal motion.
281
Arrhythmogenic right ventricular cardiomyopathy: Most affected dogs with ARVC have no detectable echo abnormalities. Some boxers, with arrhythmia, have LV .............., but it is not a common occurrence.
Careful evaluation of the right side of the heart may show some enlargement and dysfunction, but this is a challenge.
Most affected dogs with ARVC have no detectable echo abnormalities. Some boxers, with arrhythmia, have LV dysfunction, but it is not a common occurrence.
Careful evaluation of the right side of the heart may show some enlargement and dysfunction, but this is a challenge.
282
Myocardial infarction: Does not occur frequently in animals and when it does is typically secondary to other cardiac disease such as aortic stenosis, cardiomyopathy, neoplasia, or endocarditits.
Does not occur frequently in animals and when it does is typically secondary to other cardiac disease such as aortic stenosis, cardiomyopathy, neoplasia, or endocarditits.
283
Atherosclerosis occurs in dogs, especially in hypothyroid animals. The features of acute myocardial ischemia on echo include?
Reduced wall or septal systolic thickening, dyskinetic wall motion, and systolic thinning as opposed to thickening of the wall or septum. The infracted myocardium will become thinner and appear echo dense as the affected areas become fibrotic.
284
When an area of muscle becomes infracted, the percent systolic thickening ...........
decreases.
Fig 7.53, 7.54
This is evident on 2D and M-mode images if done carefully.
285
Is the decrease in systolic thickening gradual in infracted muscle areas?
is not gradual from infracted areas to adjacent normal areas. It is a sudden decrease in thickening.
286
The appearance of reduced motion toward the center of the ventricular chamber during systole on transverse or long-axis real-time images reveals infracted areas of myocardium but usually overestimated the extent of the affected area. Actual analysis of systolic thickening in the region will define the extent of the affected segment more accurately.
The appearance of reduced motion toward the center of the ventricular chamber during systole on transverse or long-axis real-time images reveals infracted areas of myocardium but usually overestimated the extent of the affected area. Actual analysis of systolic thickening in the region will define the extent of the affected segment more accurately.
287
While percent systolic thickening is an abrupt change between affected and non affected myocardium, wall motion abnormalities overlap between affected and adjacent areas of myocardium. These areas may display paradoxical motion and are called?
Dyskinetic.
288
Myocardial infarction: Acutely: features?
Regional areas of decreases systolic LVW or VS thickening or systolic thinning of VS
289
Myocardial infarction: Chronically: features?
Fibrosis and thin areas of muscle are seen with old infarction.
290
When an area of muscledispalys systolic thinning it is always associated with infarcted muscle.
Fig 7.55
291
The extent of the infarction in man involves less than .... of the myocardium when there is any evidence of systolic thickening in the segment of wall or septum being evaluated.
20%
292
Not all abnormally moving or thickening myocardium is indicative of permanent damage. Myocardial muscle may simple be stunned or hibernating. Function will spontaneously return to normal on its own if this is the cause of poor muscle contraction.
Not all abnormally moving or thickening myocardium is indicative of permanent damage. Myocardial muscle may simple be stunned or hibernating. Function will spontaneously return to normal on its own if this is the cause of poor muscle contraction.
293
Myocardial contusions and traumatic myocarditis resulting from trauma may also impair myocardial function. Features seen echocardiographically on 2 D images include increased diastolic wall or septal thickness in the affected segment, increased echogenicity of the affected myocardium, and decreased systolic thickening in the affected area. There may also be pericardial effusion and hypo echoic areas due to hematoma within the myocardium. The increased wall thickness is associated with edema of the injured muscle, and the increased echogenicity is the result of hemorrhage and altered tissue structure.
Myocardial contusions and traumatic myocarditis resulting from trauma may also impair myocardial function. Features seen echocardiographically on 2 D images include increased diastolic wall or septal thickness in the affected segment, increased echogenicity of the affected myocardium, and decreased systolic thickening in the affected area. There may also be pericardial effusion and hypo echoic areas due to hematoma within the myocardium. The increased wall thickness is associated with edema of the injured muscle, and the increased echogenicity is the result of hemorrhage and altered tissue structure.
294
Myocardial contusions and traumatic myocarditis resulting from trauma: Studies show that myocardial perfusion remains normal or may actually increase and that ischemia is not responsible for the decrease in thickening of the affected area. The effect is similar to that of stunned myocardium, and function will spontaneously return with time. The poor function may be related to ..........and........... in the area creating less myocardial compliance within the affected segment.
The poor function may be related to edema and hemorrhage in the area creating less myocardial compliance within the affected segment.
