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View Full Version : Re: TK's recent Echo...The good, the bad, and the confusing


Phil P.
December 5th 05, 12:08 PM
"Nomen Nescio" ]> wrote in message
...
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>
> TK got his 6 month echocardiogram at Tufts last week
> with somewhat mixed results regarding his HCM.
>
> The Good:
>
> "TK's echocardiogram does not show any significant progression
> of his disease and some parameters are actually better."
>
> wIVSd = .64 was .69
> wLVWd = .62 was .66
>
> "ISACHCib Hypertrophic cardiomyopathy with minimal left atrial
> enlargement. There appears to have been some regression in
> LA size, LV wall thickness, and there may be less mitral regurgitation
> today"



That's not good-- that's great!


>
> "TK has lost about 5 pounds from the last time he was here"
> "He is in excellent body condition"
>
> The Bad:
>
> "a IV/VI systolic murmur" (worse than the previous visit)
>
> "He had one premature beat as well while we were listening
> to him."
>
> wIVSs = 1.13 was .97
> wLVWs = 1.18 was 1.07
>
> The Confusing:
>
> TK's regular vet found that the murmur had almost
> disappeared back in August. Now it's up to a 4 - 6.
> The explanation that I was given at Tufts was that
> if the stethoscope isn't in just the right position, then
> it's hard to hear the murmur. This was the same vet
> that originally found the murmur and referred us to
> Tufts, so I find it difficult to believe that that she missed
> it in August (especially since she went for the electronic
> stethoscope after she couldn't hear the murmur at all
> with the regular stethoscope).
> TK was very upset at Tufts and his heart felt like it
> was going to explode as I held him....that may account
> for a more severe murmur. But to go from near 0 in
> August to 4 - 6 in November just does NOT sit right with
> me. I can't help thinking that there may be some unknown
> factor in play, here.


If he was very excited, the murmur would be more pronounced. Also, don't
forget, the grading system is rather subjective.



>
> The other thing that concerns me is the way he's shed
> weight so quickly. According to the scale at Tufts,he
> lost 4 lbs in 3 1/2 months (our measurement puts it closer
> to 3 lbs). That's quite a loss for a cat that gets 3 cans
> of Fancy Feast and about 10 gms of Hills m/d (dry)
> each day.
>
> Anyway, I can't put my finger on it, but something just
> doesn't "feel" right, here. I can't help thinking that there's
> something going on that everyone is missing.


When was the last time you had his T4 concentration checked?
Hyperthyroidism would explain the murmur and the weight loss. Was his blood
pressure checked?


Phil

Phil P.
December 6th 05, 02:36 PM
"Nomen Nescio" ]> wrote in message
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> From: "Phil P." >
>
> >That's not good-- that's great!
>
> I would have been thrilled with the report had it not
> been for the 4 - 6 murmur and the skipped beat. They
> did an EKG because of the skipped beat and said
> things looked pretty normal. The report says "NSR
> with a rate of 200 bpm and a LV enlargement pattern
> (R wave)"
>
> >If he was very excited, the murmur would be more pronounced. Also, don't
> >forget, the grading system is rather subjective.
>
> TK was VERY upset about the whole ordeal. Plus he
> had a few different people handling him. They were
> running a bit behind at Tufts so we had to wait a while,
> also. First a 4th year student checked him out, then
> he was back in the carrier, then a cardiologist (resident)
> checked him out and did some instruction with the 4th yr
> student, then back in the carrier, then into the ultrasound
> room, then he was held down on the table for Dr Rush to
> do the ultrasound (and gave the 4th yr student a nip to
> express his displeasure with the whole thing which then
> got him "the hood"), then back in the carrier, then out again
> for the ekg, then back in, then out again for Dr Rush to
> check something else with the ultrasound (some type of
> aortic velocity profile (doppler). Add in a 1 3/4 hour drive
> in Thanksgiving traffic to get there and 2 1/2 hours to get
> back and the poor little guy had a rough day.


I'd say that would do it! Did he say where the murmur is (e.g., mitral)?
Tell your wife you want a Littmann 4000 electronic stethoscope for
Christmas. The new ones come with sound analysis software so you can see
what you're hearing through the steth on your computer monitor-- you can
save the file to disk and send it to Dr. Rush as a record of TK's heart
sounds when he's calm at home. I tried to order the software for my 9000
but they said it won't work- I don't see why it wouldn't- both units record
and send the recording to a computer. I think they're just trying to sell
me a new 4000!



> The doppler showed "The aortic velocity is still increased
> at 2.7 m/s with dagger profile and E-A reversal is still
> noted". I'm not quite sure what that means, but Dr Rush
> said it's somewhat expected with TK's condition.


E:A reversal is a LV relaxation abnormality- its the reversal of early and
late filling waves. Dr. Martin can explain it much better than me- he's a
vet and also trained in ultrasonography. (I'm glad he's back!)

Aortic velocities of 2 to 4.5 m/sec.are usually characteristic of the
obstructive form of HCM. Did Dr. Rush say TK has the obstructive form of
HCM?



>
> >When was the last time you had his T4 concentration checked?
> >Hyperthyroidism would explain the murmur and the weight loss. Was his
blood
> >pressure checked?
>
> They didn't check his bp this time. I would have liked
> to have it done but I didn't even think of it in the middle
> of all the activity.
> After TK's echo in May he had to get a recheck on a
> low white count in a blood test about a month earlier.
> I asked his regular vet about doing a thyroid check
> and she said it didn't need to be done because of his
> young age (we guess he's about 2 1/2 yo, now). She
> said increased T4 is not an issue in cats under 6 yo
> and in 17 yrs as a vet, she's never seen hyperthyroidism
> in a cat under 8 yo. Dr Rush never mentioned
> hyperthyroidism as a possible cause, either. Although
> I never explicitly asked about it.
> If you know of an exception to the "no hyperthyroidism
> in young cats" rule, though, I'll bring him to the vet and
> get him tested.


The youngest I've heard of is 4 but never 2 1/2. I forgot TK is that young.
HCM in a cat his age is rare. For HCM to occur in a cat his age, I think its
probably congenital. Familial HCM has been documented in several breeds,
so, I don't see why it can't haapen in DSHs.


I hate having to disagree with vet's, but
> it wouldn't be the first time.


No, I think he's right.



> I think the weight loss can be attributed to your suggestions
> as to how to keep him on a proper diet, the shift to canned
> food, and my suspicion that the scale at Tufts may be a bit
> out of calibration. They even put him on the scale twice
> because the number seemed low. But he seems to be in
> "great shape". He's getting a little bit more food, now, so
> we'll see if his weight stabilizes. Since Thanksgiving, his
> weight has not changed (I wish I could say the same thing
> about myself :) ).

He shouldn't lose more than a pound/4 weeks. Fancy Feast averages about 80
kcal/3 oz. can- the seafood varieties average about 60. 10 g of m/d = about
40 kcals. 280 kcals a day is about right for a 13-14 lb cat. How much does
he weigh?


>
> TK's a lucky cat to have so many good people looking
> after him.


I think you lucked out with Dr. Rush- and TK lucked out with *you*!

Btw, did you ever get around to reading the articles I sent you by Dr. Rush?


>
> As always, Thank's for your concern, help, and advice.
> Any suggestions are greatly appreciated.


I think you're on the right road.

Best of luck,

Phil

Phil P.
December 7th 05, 05:01 PM
"Nomen Nescio" ]> wrote in message
...
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>
> From: "Phil P." >
>
> >I'd say that would do it! Did he say where the murmur is (e.g., mitral)?
>
> It seems like it's mostly coming from the mitral regurgitation.
> The report says "IV/VI systolic murmur right sternal border,
> III/Vi systolic murmur left sternal border. Prominent apex beat."


Yep, its a regurgitant murmur- a systolic murmur in the mitral area.


>
> >Tell your wife you want a Littmann 4000 electronic stethoscope for
> >Christmas.
>
> I wouldn't know what to do with it.

What's so nice about the 4000 is that you don't have to know anything- it
records all the heart sounds. Your cardiologist can interpret the sounds and
explain what they are and what they mean. Its a great way to learn. All you
really need to know is where the heart is! ;) Making a recording of TK's
heart sounds while he's calm at home is more accurate than when he's
stressed and excited. A II/VI can become a IV/VI when a cat is excited and
can make you think the murmur is a lot worse than it really is.



One thing I have learned
> about stethoscopes is that there's a real art to working
> with one.

Auscultation is truly an art-- especially in cats! Their hearts are so
tiny- less than an ounce- and they beat so fast that its not easy to
distinguish between heart sounds. I was lucky when I was learning because
my vet had a teaching steth- a steth with two headsets connected to the same
chestpiece- so he could explain each sound as I was hearing it. I still have
trouble sometimes.



Hell, the 4th year vet student that checked TK
> needed some coaching from the resident cardiologist to
> place the steth properly.

The murmur of mitral regurgitation is usually heard best at the left apex.
A murmur can radiate to areas of the heart other than its point of origin. A
cat's heart is so small that its sometimes difficult to pinpoint the source
with a standard size chestpiece. I find it easier to pinpoint the source
with a small infant or pediatric steth. If an electronic steth is out of
the question, you might want to pick up a good Littmann Pediatric steth-
they only cost about $80. Here's picture of the different sizes. The steth
on the right is my electronic 9000; the steth in the middle is my Master
Cardiology with an adapter that reduces the diameter of the chestpiece and
the small pink steth is my pediatric steth.(I know, pink- I didn't specify a
color) The pediatric steth works a little better than the Master with the
because is easier to maneuver on a cat:

http://www.maxshouse.com/instruments+equipment/stethoscopes.jpg

>
> >E:A reversal is a LV relaxation abnormality- its the reversal of early
and
> >late filling waves. Dr. Martin can explain it much better than me- he's
a
> >vet and also trained in ultrasonography. (I'm glad he's back!)
> >
> >Aortic velocities of 2 to 4.5 m/sec.are usually characteristic of the
> >obstructive form of HCM. Did Dr. Rush say TK has the obstructive form of
> >HCM?
>
> "SAM/Dynamic LVOT obstruction"


SAM= systolic anterior motion. LVOT= left ventricular outflow tract.

SAM is usually the cause of dynamic left ventricular outflow obstruction in
cats with the obstructive form of HCM. The hypertrophy of the septum
interferes with the ejection of blood through the LVOT. Thus, the LV must
generate higher pressure to get the blood through the LVOT- the higher
pressure creates a venturi effect that pushes or pulls the mitral valve
leaflet into the LVOT when the LV contracts (systole). That's basically
what systolic anterior motion means. Mitral regurgitation occurs when the
mitral leaflet is pulled away from the mitral opening and blood leaks back.
I hope Dr. J will correct me if I didn't explain it properly.




> Is that as bad as it sounds?


"bad" is relative. Its not good because it indicates heart disease. But its
basically "normal" for cat with obstructive HCM.


> I assume that the higher velocities are worse.


Yep. His isn't very bad.


>
> >The youngest I've heard of is 4 but never 2 1/2. I forgot TK is that
young.
> >HCM in a cat his age is rare. For HCM to occur in a cat his age, I think
its
> >probably congenital. Familial HCM has been documented in several breeds,
> >so, I don't see why it can't haapen in DSHs.
>
> DSH?


Domestic short hair. Wait- didn't you say TK is Maine Coon mix? Familial
HCM was first discovered in a family of Maine Coons- HCM is an autosomal
dominant defect in the breeds in which inheritance is known.


> The apparent diminishing of the murmur in August
> is driving me nuts. I can't help thinking that there was
> something that was not affecting him over the summer
> that is now. The murmur seems to have developed over
> last winter. Midsummer it's almost gone. November it's
> back again. House closed up in winter...windows open
> in summer.

That's a good point for environmental allergens and cats with asthma or
hypersensitivity reactions when the concentration of allergens increase
because the house is closed up- but not for a murmur. Different mechanism.
If his breathing became labored or short- I'd say could be. But not for a
murmur.



I keep wondering if it's something environmental
> in this house, but, damn, I can't single anything out
> except the apparent connection to the house being closed
> up in winter. I've got 2 CO detectors that read 0. We keep
> the house clean, run 5 air filters (HEPA 99%) throughout the
> house, no air fresheners, mostly pet safe cleaners and
> even those are used carefully. I'm drawing a blank, but
> I can't get the seasonal correlation out of my mind. I've
> even had the thought of "maybe I should let him go outside".
> Then I think about the den of coyotes that the Fish and Wildlife
> Dept. found a mile from our house last year where they picked up
> over 40 pet collars scattered around the area, and realize
> letting him out may not be such a good idea.


I'm telling you- I really think the murmur *seemed* worse because he was
highly stressed and excited. Murmurs are always more pronounced when a cat
is excited- especially when his heart rate increases to >200 bpm. So, relax
;)



>
> >He shouldn't lose more than a pound/4 weeks. Fancy Feast averages about
80
> >kcal/3 oz. can- the seafood varieties average about 60. 10 g of m/d =
about
> >40 kcals. 280 kcals a day is about right for a 13-14 lb cat. How much
does
> >he weigh?
>
> According to the scale at Tufts, TK weighed 9 lbs 5 oz.
> But I'm suspicious of it's accuracy. TK should have a
> weight of about 10 lbs. On roughly 3 cans of FF, mostly
> grilled chicken, and 10 gms of the m/d, his weight dropped
> from 13 lbs in the beginning of August (vets office) to
> the 9 lbs 5 oz (Tufts). We weigh him at home (cheap scale
> but good repeatability) and thought he was just a little
> over 10 lbs. He is a pretty energetic cat (we describe him
> as having 2 speeds.......sleeping, and HOLY ****!!).


My guess is the scale at Tufts is out of calibration- the students probably
sit on it or use it for a snack table and knocked it out of calibration.
You'll always find variations between scales- except Tanitas! You could
probably pick up a Tanita 1583 pediatric scale on eBay cheap. They're very
accurate. I love mine.


>
> >Btw, did you ever get around to reading the articles I sent you by Dr.
Rush?
>
> Sure did. You must have done a good job of
> educating me about HCM because I actually
> understood what I was reading.


Naa, he's just very easy to understand. I like his writing style. Is he
that easy to understand in person?

The next time you see him, ask him about nattokinase. Its a new dietary
supplement made from fermented soybeans that's supposed to have potent
fibrinolytic properties that's supposed to prevent and even dissolve blood
clots (aortic thromboembolism). Clots are one of the most devastating
complications associated with HCM. I haven't been able to find any reliable
clinical studies- just tons of anecdotal reports praising the stuff.




>
> >I think you're on the right road.
>
> I wish I was sure of that. Actually, I wish the proverbial
> light bulb would flash on and I could go "Aha, that's what's
> causing the problem!" and I could correct it and TK
> would get better.

You caught it early enough to make a *big* difference. I think putting him
dilatizem right away was a *very* wise move and was probably the reason why
his hypertrophy *decreased*. If his HCM was progressing, the IVS and LVW
thickness would be increasing- not decreasing. So, I guess you can say he
*is* getting better! ;))). Just keep going the way you're going and TK will
be around for many more years.

Best of luck,

Phil

Phil P.
December 7th 05, 06:53 PM
"Phil P." > wrote in message
k.net...

If an electronic steth is out of
> the question, you might want to pick up a good Littmann Pediatric steth-
> they only cost about $80.

On second thought, the Cardiology III has two tunable diaphragms- one side
is for use on adults, and the other side is a pediatric size. The sound
quality and intensity of the Cardiology III is a lot better than the Classic
II Pediatric
and Infant Stethoscopes.

Phil