Myocardial III/Arterial Thromboembolism Student Slides PDF

Myocardial III/ Arterial thromboembolism Lauren Markovic, DVM, DACVIM (Cardiology), FACVIM (Interventional Cardiology) Muddy points/questions/updates from myocardial I & II Unaffected limb Affected limb Median Lactate...

Myocardial III/ Arterial thromboembolism Lauren Markovic, DVM, DACVIM (Cardiology), FACVIM (Interventional Cardiology) Muddy points/questions/updates from myocardial I & II Unaffected limb Affected limb Median Lactate 3.5 mmol/L (range 2.2 – 5.7) 11.5 mmol/L (range 5.2 – 17) Median blood glucose 250 mg/dL (range 112 – 430) 103 mg/dL (range 26 – 185) Muddy points/questions/updates: Infrared thermography  Muddy points/questions/updates: Clinical Case Studies – Cardiac Education Group Website  Myocardial III/ Arterial thromboembolism Abbreviation table ATE = arterial thromboembolism FATE = feline arterial thromboembolism LA = left atrium RV = right ventricle tPA = Tissue plasminogen activator  Feline arterial thromboembolism review Clinically devastating disease Cardiogenic arterial thromboembolism Source of thrombotic material is from a cardiac chamber Typically left atria/auricle Associated with underlying myocardial disease Hypertrophic cardiomyopathy Restrictive cardiomyopathy Dilated cardiomyopathy Unclassified/nonspecific cardiomyopathy Arrhythmogenic RV cardiomyopathy Neoplasia is a less common cause of ATE May be in concurrent congestive heart failure (~60%)  Sparky 12 yo MN Sphynx Right forelimb lameness and tachypnea 5 days prior – treated with furosemide, buprenorphine and Plavix at primary vet Additional medications on intake Prednisolone (history inflammatory bowel disease) Methimazole (history hyperthyroid) Referring radiograph review  Physical Exam Quiet, alert Non-weight bearing lameness RFL, Heart rate 190bpm swelling below carpus and necrosis Respiratory rate = 30, mild effort and bruising on palmar side Temperature = 100.6 F Blood pressure 115 mmHg systolic MM pink, CRT < 2 sec Regular heart rhythm No heart murmur Femoral pulses normal Normal lung sounds No jugular distension  Case Question Which is the most likely diagnoses based on history and physical exam? A) Renal thromboembolism B) Brachial thromboembolism C) Saddle thrombus Case 1 – is Sparky in heart failure? Quiet, alert Heart rate 190bpm Respiratory rate = 30, mild effort Temperature = 100.6 F MM pink, CRT < 2 sec Regular heart rhythm No heart murmur Femoral pulses normal Normal lung sounds No jugular distension Non weight bearing lameness  Next steps… 25mm/s  ECG diagnosis What’s your diagnosis? Any therapeutics necessary?  Bloodwork abnormalities PCV/TP - 33%/9.0 Hypokalemia 3.0 (L) BUN 65 (H) Creatinine 1.4 hyperphosphatemia 6.8 (H) hypoalbuminemia 3.1 (L) T4 4.25 (H) Echocardiogram  Echocardiogram Assessment normal LV wall and interventricular septal thickness mildly dilated left ventricular RV RA chamber size moderately dilated left and right LV atria Systolic function is normal LA There is spontaneous echogenic contrast within the left auricle. Echocardiogram – left atrium/auricle Anesthetic considerations?  Sparky anesthetic protocol Preanesthetic medications Methadone Midazolam Induction agent Propofol Fluid type: LRS 2ml/kg/hr ECG monitoring: single VPCs, ventricular bigeminy Treatment for the ventricular arrhythmia?  Wound debridement Aerobic and anaerobic culture Medications – for what condition is each medication being used for? Furosemide Potassium gluconate Gabapentin Methimazole Clavamox Prednisolone Buprenorphine Culture results Aerobic culture Staphylococcus felis – light growth Streptococcus canis – Moderate to heavy growth Anaerobic culture – no organisms Recheck 4 days post  1 week recheck Initial CXR Recheck Bloodwork recheck ~ 2 months later  Management strategies - FATE Acute Treat life-threatening CHF Assess neurologic, muscular, and vascular function Assess metabolic status Medical therapy Pain medication – opiods, or fentanyl in severe cases Anticoagulants & antiplatelets Thrombolytics – rare in cats Which of these disease/s can lead to FATE? Hypertrophic cardiomyopathy Restrictive cardiomyopathy Non-specific cardiomyopathy Arrhythmogenic right ventricular cardiomyopathy Dilated cardiomyopathy  Summary ATE is a clinically devastating disease Cats with cardiomyopathy are predisposed to formation of intracavitary thrombi due to blood stasis, endothelial injury, hypercoagulable state Anti-thrombotic drugs are antiplatelets and anticoagulants Clopidogrel is superior to aspirin Management – improve blood flow, pain meds, induce hypocoagulable state, treat CHF if present Survival is low, but cats can stabilize in 24-72 hours Questions