ShiversCase Background

Name Shivers
Age 11 years
Sex Male, neutered
Breed Miniature Poodle

Please review Shivers' clinical history

Patient has a primary complaint of rapidly progressive coughing (began 2 weeks ago, but is much more severe over the past 48 hours) accompanied by lethargy and increased respiratory effort. Has a history of a murmur, first detected 2 years ago.

View Shivers' right lateral radiograph  
View Shivers' ventrodorsal radiograph  


Location of images: Thoracic radiographs obtained.

Views of images: Right lateral and ventrodorsal thoracic views.


Technical issues: Good. Could be collimated to exclude the abdomen.

Cardiac size including VHS: VHS is 12.7; There is severe left-sided heart enlargement with obvious loss of caudal waist, indicating left atrial dilation. On the VD view, the cardiac silhouette appears to be wide and somewhat elongated, with a broad left auricular bulge at the 2-3 O'clock position on the cardiac silhouette, consistent with significant left atrial chamber enlargement.

Other Findings: Distended pulmonary veins, Moderate perihilar/caudodorsal interstitial pattern (Lat), There is a caudal interstitial pattern that is located toward the midline and radiates outward toward the thoracic wall. With the heaviest radiographic density overlying the left apex of the cardiac silhouette.

 Diagonosis: Left-sided Congestive Heart Failure (pulmonary edema) likely secondary to degenerative valve disease.
 Discussion: The enlarged heart, venous distention and distribution of the interstitial pattern are all consistent with congestive heart failure. The murmur and breed suggest degenerative valve disease as the most likely cause of the heart enlargement and pulmonary venous congestion. An echocardiogram was performed and revealed moderate to severe left atrial dilation with moderate left ventricular dilation cardiac size. Severe thickening and prolapse of the anterior leaflet of the mitral valve. Hyperdynamic left ventricular contractility secondary to mitral regurgitation. There was a large jet of mitral regurgitation with a reduced mitral regurgitation velocity and elevated E wave velocity (mitral inflow Doppler study) both consistent with elevated atrial pressures consistent with congestive heart failure. Mild tricuspid regurgitation is present, with a high normal regurgitant velocity consistent with a mild elevation in pulmonary artery pressures (42mmHg pressure gradient). There were normal aortic and pulmonic flow velocities. No pericardial effusion present.
Treatment/Management: The patient was given a furosemide injection (30mg) subcutaneously and sent home on: Furosemide 20mg tablet every 8 hours by mouth for 3 days then decrease to every 12 hours. Enalapril 5mg tablet every 12 hours by mouth. Vetmedin 2.5mg every 12 hours by mouth. He returned in 7 days for a renal panel and repeat radiographs (see follow up films) which showed significant improvement in the interstitial pattern, but the pulmonary venous distention had not resolved. Spironolactone 12.5mg every 12 hours was added at that visit.