Sunday, June 2, 2013

Maybe A Pre-Cana Before Adopting?

Alice is a 2 year old St. Bernard. She was recently spayed and she is small for her breed. She was just adopted by a loving family who wanted to rescue a St. Bernard. They spent many weeks looking for her and were delighted when they found her. They adopted her right away and brought her to visit me for her new pet examination. I have said many times before that it is imperative to bring your new pet to your veterinarian within the first few days of adopting your new bundle of joy. 

Within a few minutes of examining Alice I was afraid that she came to them with some unexpected challenges.

Alice had a heart murmur.

Alice's heart murmur was a grade 3-4 out of 6. Six being the most severe. Because we didn't know much about Alice, and because I have heard a murmur and then had it miraculously and mysteriously disappear at the next visit, we decided to re-check Alice's murmur the next week. After three subsequent visits Alice's murmur remained the same. 

I recommended that Alice be brought to a veterinary cardiologist for an echocardiogram examination. An echocardiogram is an ultrasound of the heart.

When we are examining soft tissue structures like the liver, or pancreas, or intestines, we use an ultrasound. An x-ray (or radiograph) is used to assess bony structures, like the femur, or the spine. The best way to examine the heart is with an ultrasound. We call it an echocardiogram.

In the hands of a trained cardiologist they can measure all of the intricate special features of the perfectly engineered heart. Without the aid of the echocardiogram the general veterinarian has only the ability to listen and hear an abnormality. In trying to identify the source of the abnormal heart sound we sometimes take an x-ray to measure and view the silhouette the heart leaves on the x-ray. In the office of a general veterinary clinic we use our ears and stethoscope, and x-ray, and sometimes even an ECG (electrocardiogram) to evaluate the heart. But even with these an echocardiogram is still needed to accurately diagnose the exact problem causing the murmur. For an echocardiogram you need a cardiologist. Alice's next stop to get a diagnosis for her heart was their office.

Alice went to the cardiologist the next week. 

Her ultrasound revealed the following;
1. Severe congenital valvular pulmonic stenosis. 
2. Atrial septic defect.
3. Severe eccentric right ventricular hypertrophy
4. Severe right atrial dilation

Now that's a long list of problems! Alice's family was understandably very concerned. The cardiologist was telling them that Alice was born with a narrow pulmonary artery. The pulmonary artery is the vessel that sends blood from the right ventricle (bottom chamber) to the lungs. When the pulmonary artery is narrow the right ventricle is trying to push blood into the lungs through a small tube. And you all know what happens when you try to push a fluid through a narrower than its supposed to be tube? Well, if that tube is a strong muscular and very resilient muscle like an artery it will not dilate against the increased pressure. This causes the muscle below it (the right ventricle)to push harder to try to move the correct amount of blood to where it is supposed to be (the lungs). And what happens to every muscle that works harder? It gets bigger. For a heart with severe enough and chronic enough over exertion the right side of the heart gets larger. This is the right atrial and ventricular dilation and hypertrophy that the cardiologist found.

Alice also had an atrial septal defect. This is essentially a hole between the two sides of the atrium (the top two chambers). The heart is designed to be four chambers, separated by valves, and the four chambers are not supposed to have the ability to communicate. If they do the blood that is supposed to be pushed as the heart pumps acts like a traffic intersection with no stop lights. Blood will therefore be sent in directions and places that it is not supposed to go.

Pulmonary stenosis is one of the most frequently observed heart defects seen in dogs. PS is often found at the first puppy exam. Most clients do not notice anything abnormal in their puppies because puppies do not overexercise or over exert themselves for long enough periods of time to cause the heart defect to present itself. The first clue is the veterinary exam and the ausculted heart murmur. The cardiologist is needed to diagnose and treat the rest.

PS is most commonly seen in English bulldogs, Westies, Cocker Spaniels, Labs, Mastiffs, Miniature Schnauzers, Cavalier King Charles Spaniel, Samoyeds, beagles, chihuahuas, and keeshonds. 

A severe case of PS causes patients to be exercise intolerant that can include fainting, secondary heart failure and even death. The treatment for severe PS is balloon valvuloplasty. This is a procedure where a wire cage is placed into the patients pulmonary artery via a small incision in the leg. Under a special type of x-ray the wire cage is placed and then the wire cage is 'inflated' (hence 'balloon'). The cage stretches open by the balloon being inflated once it is in place. The narrowed artery is forced open from the inside, and then cage is left behind to hold the artery open. Although this procedure is minimally invasive and has a low risk of complications, it is very costly.

The specialty practice that saw Alice gave her family an estimate of $4300.

The family spent the next three weeks calling every rescue, every veterinary facility that performs this procedure, and everyone they could think of, and then called me.

They told me that they felt awful about not being able to pay for her surgery, but that they were going to keep her, love her, and do everything they could to keep her calm, quiet, and stress free. They may not be able to fix her heart, but they know how to protect it from further damage and they are committed to helping her the best they can.

To protect further stress on her heart she needs to avoid anesthesia and over aggressive i.v. fluids and keep her teeth brushed daily to prevent the accumulation of dental tarter which can adhere to the heart valves and further weaken her heart. She also should be warmed up before exercise and avoid exercise in hot or humid conditions. She should also stay on her monthly flea & tick preventatives and heartworm preventatives. 

The other important aspect to mention is that Alice should not be used for breeding. Because her heart defects are congenital her parents (if they were known) and the other puppies of the litter should be examined. Even if the parents did not have a murmur they should not be bred to each other again.

I will check on Alice every few months. We will monitor her murmur, keep her on medication to help her heart, avoid salt, keep her teeth very clean, and she will be loved.

If you have any questions about Alice, her diagnosis, or any other parts of her story please ask me, or any of the other contributors at pawbly

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