Antonia Mavropoulou Echocardiography in chronic valvular ...
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Page 10 - VETcpd - Vol 1 - Issue 4 For Cardiology Referrals in your area: vetindex.co.uk/cardio For Ultrasound Equipment see: vetindex.co.uk/ultrasound 16th Edition 14 The year round guide to veterinary products, supplies and services The year round guide to veterinary products, supplies and services 2014 www.vetindex.co.uk 20th Edition b Partrid VET cpd - Cardiology Peer Reviewed Echocardiography in chronic valvular degenerative disease Chronic valvular degenerative disease (CVD) is the most common acquired heart disease in the dog. This article illustrates the echocardiographic features of the disease and the criteria used for the assessment of its severity and progression. Key words: echocardiography, degenerative mitral valve disease, atrioventricular valve disease, myxomatous atrioventricular valve disease Introduction Chronic valvular disease (CVD, also known as myxomatous mitral valve disease, chronic mitral valve disease) is by far the most common heart disease in dogs. It is characterised by the degenerative thickening of the valve apparatus (leaflets and chordae tendinae) that leads to valvular regurgitation. The mitral valve can be affected alone or in combination with the tricuspid valve. The prevalence of the disease is age and breed related with older and small breed dogs being overrepresented. For this reason CVD is often suspected when a typical systolic heart murmur is detected in a patient of a particular breed and age. Definitive diagnosis is accomplished with echocardiography that, through the combination of two-dimensional (2D), M-mode and Doppler modalities, allows the recognition and staging of the disease. This article focuses on the echocardiographic features of CVD and shows how this examination can help us identify patients with more advanced disease and make therapeutic decisions. Echocardiographic diagnosis of CVD CVD is a progressive chronic disease in which small nodular lesions develop and slowly become larger and more numerous Figure 1: Left parasternal long axis view. Mild mitral valve thickening and mild prolapsed (bulging of the leaflets into the left atrium)(arrow) is seen. The color flow jet of mitral insufficiency (mosaic pattern of colour) in the left atrium is mild, involving less than 20% of the atrial chamber. LA: left atrium, LV: left ventricle, RA: Right atrium, RV: Right ventricle Figure 2: Left parasternal long axis view. Severe mitral valve prolapse and thickening is seen in this dog (arrow). The left atrium is enlarged. Color-flow Doppler shows severe regurgitation with the regurgitant jet occupying most of the left atrial chamber. LA: Left atrium, LV: Left ventricle, RV: Right ventricle Ruth Willis BVM&S DVC MRCVS RCVS Recognised Specialist in Cardiology Holter Monitoring Service Ruth qualified from Edinburgh Vet School and then spent two years in mixed practice before returning to Glasgow Vet School to start a three year residency in cardiology during which she obtained the RCVS Certificate and Diploma in Cardiology. She has held RCVS Specialist status for 10 years and currently works for Vets Now Referrals and is also a director of Holter Monitoring Service. Contact: [email protected] Visit www.vetcpd.co.uk/echo for all the videos in this article Antonia Mavropoulou DVM, MRCVS, MSc, PhD Antonia qualified from the University of Parma (Italy) in 2001. She obtained a Masters Degree in clinical aspects of cardiovascular disease in 2004. From 2004 to 2011 she was a research fellow and PhD student at Parma University. The topics of her research were the study of cardiac rhythm and conduction abnormalities and pro-inflammatory cytokines in mitral valve disease. From 2011 to 2013 she performed a cardiology ECVIM-CA residency training in Milan (Italy). Currently she is a part-time cardiologist at Davies Veterinary Specialists and also works part-time for Holter Monitoring Service. Contact: [email protected] Play Video 1 Play Video 2 LV LV RV LA LV LV LA RA RA RV RV
Transcript of Antonia Mavropoulou Echocardiography in chronic valvular ...
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VETcpd - Cardiology Peer Reviewed
Echocardiography in chronic valvular degenerative diseaseChronic valvular degenerative disease (CVD) is the most common acquired heart disease in the dog. This article illustrates the echocardiographic features of the disease and the criteria used for the assessment of its severity and progression.
Key words: echocardiography, degenerative mitral valve disease, atrioventricular valve disease, myxomatous atrioventricular valve disease
IntroductionChronic valvular disease (CVD, also known as myxomatous mitral valve disease, chronic mitral valve disease) is by far the most common heart disease in dogs. It is characterised by the degenerative thickening of the valve apparatus (leaflets and chordae tendinae) that leads to valvular regurgitation. The mitral valve can be affected alone or in combination with the tricuspid valve.
The prevalence of the disease is age and breed related with older and small breed dogs being overrepresented. For this reason CVD is often suspected when a typical systolic heart murmur is detected in a patient of a particular breed and
age. Definitive diagnosis is accomplished with echocardiography that, through the combination of two-dimensional (2D), M-mode and Doppler modalities, allows the recognition and staging of the disease. This article focuses on the echocardiographic features of CVD and shows how this examination can help us identify patients with more advanced disease and make therapeutic decisions.
Echocardiographic diagnosis of CVDCVD is a progressive chronic disease in which small nodular lesions develop and slowly become larger and more numerous
Figure 1: Left parasternal long axis view. Mild mitral valve thickening and mild prolapsed (bulging of the leaflets into the left atrium)(arrow) is seen. The color flow jet of mitral insufficiency (mosaic pattern of colour) in the left atrium is mild, involving less than 20% of the atrial chamber. LA: left atrium, LV: left ventricle, RA: Right atrium, RV: Right ventricle
Figure 2: Left parasternal long axis view. Severe mitral valve prolapse and thickening is seen in this dog (arrow). The left atrium is enlarged. Color-flow Doppler shows severe regurgitation with the regurgitant jet occupying most of the left atrial chamber. LA: Left atrium, LV: Left ventricle, RV: Right ventricle
Ruth Willis BVM&S DVC MRCVS RCVS Recognised Specialist in CardiologyHolter Monitoring Service
Ruth qualified from Edinburgh Vet School and then spent two years in mixed practice before returning to Glasgow Vet
School to start a three year residency in cardiology during which she obtained the RCVS Certificate and Diploma in Cardiology. She has held RCVS Specialist status for 10 years and currently works for Vets Now Referrals and is also a director of Holter Monitoring Service.Contact: [email protected]
Visit www.vetcpd.co.uk/echo for all the videos in this article
Antonia Mavropoulou DVM, MRCVS, MSc, PhD
Antonia qualified from the University of Parma (Italy) in 2001. She obtained a Masters Degree in clinical aspects of cardiovascular disease in 2004.
From 2004 to 2011 she was a research fellow and PhD student at Parma University. The topics of her research were the study of cardiac rhythm and conduction abnormalities and pro-inflammatory cytokines in mitral valve disease. From 2011 to 2013 she performed a cardiology ECVIM-CA residency training in Milan (Italy). Currently she is a part-time cardiologist at Davies Veterinary Specialists and also works part-time for Holter Monitoring Service.Contact: [email protected]
Play Video 1
Play Video 2
LVLV
RV
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LV LV
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VETcpd - Vol 1 - Issue 4 - Page 11
VETcpd - Cardiology
Figure 3: Left parasternal long axis view. The septal tricuspid valve leaflet is prolapsing in the right atrium (arrow). The right atrium is enlarged and the atrial septum is curving towards the left suggesting high right atrial pressure. LA: Left atrium, LV: Left ventricle, RA: Right atrium, RV: Right ventricle.
Figure 4: Although there are a lot of echocardiographic measurements and calculations that can be made to assess accurately MVD severity, the two-dimensional echocardiography remains a simple and reliable method for a subjective evaluation of cardiac size and function. This figure shows the right parasternal four-chamber view of a normal dog (A) and a dog with severe CVD (B). Marked left ventricular and left atrial dilation is seen in the affected dog (B), with marked curving of the ventricular and atrial septa towards the right. LV: Left ventricle, LA: Left atrium, RA: Right atrium, RV: Right ventricle, VS: interventricular septum, AS: Interatrial septum.
Figure 6: Left ventricular M-mode image from the right parasternal transverse view. The 2D image of the left ventricle is seen on the top of the image and structures under the cursor are displayed on the M-mode image as they change over time.
Exaggerated motion of the interventricular septum and the left ventricular (LV) free wall is observed in this dog with mitral valve disease. The fractional shortening (FS) is increased (FS 63%) and is suggestive of preserved myocardial function.S: systole, D: diastole
causing deformity, thickening and prolapse of the atrioventricular valve.
During the early stages, 2D imaging shows mild thickening and often prolapse of the atrioventricular valve and Color–Flow Doppler (CFD) documents mild regurgitation. The cardiac chambers are still of normal size (Fig. 1). As the disease progresses, the atrioventricular valve lesions become larger and more irregular and the amount of regurgitation increases. The left atrium (LA) dilates in the attempt to accommodate the extra blood volume without a significant increase in atrial and pulmonary venous pressures which would lead to pulmonary oedema. The left ventricle (LV) also enlarges to maintain an adequate forward cardiac output (Fig. 2; Video 1,2).
The mitral valve is more commonly affected but when the disease involves the tricuspid leaflets similar echocardiographic changes are detected (Fig. 3).
What are the echocardiographic features that allow discrimination between different phases of the disease?• Cardiac remodelling/dilationWhen enlargement of the left atrium and left ventricle develops we are in the presence of haemodynamically significant mitral regurgitation (MR). The dilation can be subjectively appreciated from the right parasternal long axis view when curving of the interventricular and interatrial septum towards the right is seen (Fig.4).
However, a more quantitative and accurate assessment is required, especially to assess disease progression and monitor response to treatment.
Several methods have been proposed for the measurement of left atrial size. The most commonly used one is the ratio between the diastolic short axis image of the aorta and the left atrium (Fig. 5). The magnitude of atrial dilation in chronic mitral valve disease reflects the severity of the regurgitation. However this is not applicable in cases of acute regurgitation (e.g. chordae tendinae rupture; see complications below) in which there is not enough time for cardiac remodelling and therefore left atrial size may underestimate the severity of the disease.
Left ventricular remodelling may be assessed with M-mode and 2D modalities. Left ventricular size measurement is usually performed in M-mode (Fig. 6) and
LVIDd: Left ventricular internal dimension in diastole (36.1mm) LVIDs: Left ventricular internal dimension in systole (13.4mm)
LV LVRV
RA LA LA
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Figure 5: The right parasternal transverse view at the level of the heart base is the most common plane used for the evaluation of left atrial size.
The ratio between the diastolic short axis image of the aorta and the left atrium is calculated. Care should be taken not to include the pulmonary veins (at their entrance in the atrium) in the left atrial measurement.
The Left atrium/Aorta ratio (LA/Ao) in this dog is suggestive of severe left atrial dilation (LA/Ao= 2.8). LA: Left atrium, Ao: Aorta, PV: Pulmonary vein.
LVIDdLVIDsSD
Fractional shortening is calculated as follows: (LVDd-LVDs/LVDd) x 100. i.e. (36.1-13.4/36.1) x 100 = 63%
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