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Abdominal Distension

Patient Information

Gender
Male, Intact
Species
Canine

Keywords

Clinical Signs

Images

June boon method La/Ao shows normal left atrial volume despite mitral insufficiency. The MR was therefore compensated and not clinically significant.
Note the echogenic linear heartworms in the lower left of the image at the 7 o`clock position at 10 cm of depth.
The LV m-mode shows normal left sided volume and function but note the flattening of the LV septum in the b-mode portion of the image. This indicates significant right sided volume overload and increased RV pressures.
Severe tricuspid insufficiency was seen consistent with pulmonary hypertension. Pulmonary hypertension was noted with a jet of 3.87 m/sec.

Chasin' the vermin! Swollen abdomen, put a probe on it, see and tap the ascites, see the hepatic vein dilation, move to the thorax to see the cause of passive congestion. This is exactly what happened on this ascites case and is an example of daily "stick & move" diagnostic efficiency with the sonogram. "Those there worms can't outrun the probe" in the October 2013 SonoPath case of the month.

History

An intact male mixed breed dog was presented for evaluation of 4-5 days of progressive abdominal distension. Abnormalities on laboratory work were heartworm positive and anemia. Survey radiographs showed cardiomegaly and a possible abdominal mass.

Clinical Differential Diagnosis

Cardiac - right heart failure secondary to heartworm, pericardial effusion, cardiomyopathy Abdominal mass - neoplasia/granuloma/abscess/cyst of spleen, liver, kidney.

Image Interpretation

The echocardiogram revealed an enlarged right heart with right atrial enlargement and significant tricuspid regurgitation. Tricuspid insufficiency was noted at 3.87 m/sec. The main branch of the pulmonary artery was enlarged and a large amount of heartworms were noted. Smoke was noted in the right atrium. The mitral valve was insufficient. The left atrium was of normal size. Tricuspid insufficiency velocity 3.87 m/sec. Mitral insufficiency velocity 5.65 m/sec.

Sonographic Differential Diagnosis

Right sided heart failure. Large amount of heartworms noted in the main branch of the pulmonary artery. Pulmonary hypertension was noted with a jet of 3.87 m/sec. Given the changes seen on echocardiographic examination this patient would be an ideal candidate for basket retrieval of heartworms. Until this procedure is performed the patient should be treated with aspirin at 1 mg/kg every other day, Pimobendan at 0.25-0.3 mg/kg b.i.d. and Sildenafil at 1 mg/kg b.i.d. The Sildenafil dose can be increased to 1.5 mg/kg b.i.d. over 10 days. Lasix should be instituted at 1-2 mg s.i.d. Given the significant amount of heartworms noted in the pulmonary artery coupled with the patient's clinical signs the patient's prognosis is guarded at this time. Ideally, it would be prudent to perform a blood pressure and ECG in this patient.

DX

Heartworms, pulmonary hypertension.

Outcome

No further outcome available.

Comments

No further outcome. Given the changes seen on echocardiographic examination this patient would be an ideal candidate for basket retrieval of heartworms.

Videos

Right parasternal 4-chamber long axis view demonstrating severe right atrial and right ventricular volume overload owing to heartworm burden. The sonographer had to slide the probe dorsally along the rib cage to achieve this 4-chamber view given the cardiac rotation and displacement away from normal positioning owing to the severe right sided volume overload.
Apical 4-chamber view demonstrating an inversion of normal volumes as the left heart now has the lesser volume compared to the right heart (left of screen).
Right parasternal heart based view demonstrating a severely enlarged right atrium in the 9 o'clock position, overwhelming right ventricle and pulmonary artery (11-6 o'clock position), and visible echogenic heartworms in the main branch of the pulmonary artery in the 7 o'clock position at 10 cm of depth.