EchocardiographyinEchocardiographyinTipsandDr.GerhardDiplomateACVIM(cardiology)DiplomateECVIM-CA(InternalWhytoperformanEchoinWhytoperformanEchoinaSymptomssuggestiveofMurmur心雜音Galloprhythm奔馬律Dyspnea呼吸困難Arrhythmia????Screening/BreedingElevatedNT-proBNP(>100Tip1:howtoperformanTip1:howtoperformanechoina第1招：怎樣給貓做超聲心動呢?Catsshouldbegentlyrestrainedinlateralrecumbency(asdogs)貓需要溫柔的側臥保定（同犬一樣Exception:catswithdyspnea→→trytodoonlyaquick????lookforLAsizelookforpleuraleffusion?Use7Mhztransducer(orhigherTip2:Sedation第2招：給貓FelineSedationProtocolsasymptomaticTip2:Sedation第2招：給貓FelineSedationProtocolsasymptomaticcatneedingMidazolam0.2mg/kg+hydromorphone0.1mg/kgIMinthesamesyringe咪達唑侖0.2mg/kg+氫嗎啡酮Acepromazine0.05-0.1mg/kg+0.1mg/kgSQorHydromorphone0.05mg/kg+midazolam0.1mg/kgCatwithcongestiveheartButorphanol0.2mg/kg+midazolam0.2oracepromazine0.05mg/kgifveryuncooperative)IM(furosemidebeforeultrasoundifdyspneic)segef02WhyareCatHeartSoundsSoDifficulttoWhyareCatHeartSoundsSoDifficulttoCharacterize?WhyareCatHeartSoundsSoDifficulttoCharacterize?WhyareCatHeartSoundsSoDifficulttoCharacterize?Gallopheartsoundscanbehardto?WhyareCatHeartSoundsSoDifficulttoCharacterize?WhyareCatHeartSoundsSoDifficulttoCharacterize?GallopheartsoundscanbehardtoMurmursincatsallsoundthe??WhyareCatHeartSoundsSoDifficulttoCharacterize?GallopWhyareCatHeartSoundsSoDifficulttoCharacterize?GallopheartsoundscanbehardtoMurmursincatsallsoundtheMurmursareoften???WhyareCatHeartSoundsSoDifficulttoCharacterize?GallopWhyareCatHeartSoundsSoDifficulttoCharacterize?GallopheartsoundscanbehardtoMurmursincatsallsoundtheMurmursareoften???WhyareCatHeartSoundsSoWhyareCatHeartSoundsSoDifficulttoCharacterize?WhyareCatHeartSoundsSoDifficulttoCharacterize?WhyareCatHeartSoundsSoDifficulttoCharacterize?Catsaresmall;thevalveareasareclose?ThepositionoftheheartinthethoraxchangesManycatshaveaveryrapidheartrateSomecatspurrandsomecatsare???WhyareCatHeartSoundsSoDifficulttoCharacterize?CatsWhyareCatHeartSoundsSoDifficulttoCharacterize?Catsaresmall;thevalveareasareclose?ThepositionoftheheartinthethoraxchangesManycatshaveaveryrapidheartrateSomecatspurrandsomecatsare???WhyareCatHeartSoundsSoDifficulttoCharacterize?CatsareWhyareCatHeartSoundsSoDifficulttoCharacterize?Catsaresmall;thevalveareasareclose?ThepositionoftheheartinthethoraxchangesManycatshaveaveryrapidheartrateSomecatspurrandsomecatsare???Heartmurmurs心雜Heartmurmurs心雜Thetwomostcommoncardiacmurmursinadultcatsare:成年貓最常見的2種心雜音為SAM:systolicanteriormotionDRVOTOdynamicrightventricularoutflowtractobstruction右心室流出通道阻塞???Heartmurmurs心雜ThetwoHeartmurmurs心雜Thetwomostcommoncardiacmurmursinadultcatsare:成年貓最常見的2種心雜音為SAM:systolicanteriormotionDRVOTOdynamicrightventricularoutflowtractobstruction右心室流出通道阻塞???Theneglectedarea:ventralthoraxovertheTip3:MurmursinTip3:Murmursincatsareoften→→soifyouheardamurmurandcan‘tfinditon→→trytoelevatetheheart???????barklikea?tease“thecatblowatthe….butbecarfullTip4:howtodetectTip4:howtodetectSAMSystolicanteriormotionofmitralvalveSAM=二尖瓣的收縮期向前運動reasonformurmurinHCMSAMcausesdynamicobstructionofLV-outflowtractdynamicSAM導致左心室流出通道動態(tài)性阻塞→→動態(tài)心雜fastHR心率快→→slowmurmur心率慢→→雜音SAMSAMDynamicLVOT動態(tài)右心室流出通道DynamicLVOT動態(tài)右心室流出通道阻 Tip5:howtoTip5:howtodetect“DR第5招：如何診斷“DRDRVOTO:dynamicrightventricularoutflowtractobstructionDRVOTO:右心室流出通道阻塞othername:DIPS(dynamicinfundibularsystolicnarrowingofRVoutflowusuallybengin,dynamiccauses:hyperdynamiccirculatorysituations-anemia,hyperthyroidism,inflammationrarelywithHCMMechanismsofDynamicRVOTMechanismsofDynamicRVOTNormalDRVOTO=DSPSorDIPSSystolicnarrowingofRV右心室漏斗部心縮DynamicrightventricularoutflowDynamicrightventricularoutflowtractColorDopplerturbulentFlowinRVoutflowPWorCW-late-systolicpeakincreasedvelocity>速度增加>“DRVOTO”:UsetheLA/AOviewtoseetheRVOT“DRVOTO”:“DRVOTO”:UsetheLA/AOviewtoseetheRVOT“DRVOTO”:利用左心室/主動脈切面看右心室流出通道“DRVOTO”:UsetheLA/AOviewtoseetheRVOT“DRVOTO”:“DRVOTO”:UsetheLA/AOviewtoseetheRVOT“DRVOTO”:利用左心室/主動脈切面看右心室流出通道“DRVOTO“DRVOTOCW-Doppler“DRVOTO”:DynamicRVOTRVOTVelocityDynamicRVOTRVOTVelocity>2.0右心室血流流出速度2.0PrimaryMyocardial原發(fā)性心肌PrimaryMyocardial原發(fā)性心肌PrimaryMyocardial原發(fā)性心肌PrimaryMyocardial原發(fā)性心肌PrimaryMyocardial原發(fā)性心肌PrimaryMyocardial原發(fā)性心肌PrimaryMyocardial原發(fā)性心肌PrimaryMyocardial原發(fā)性心肌PrimaryMyocardial原發(fā)性心肌PrimaryMyocardial原發(fā)性心肌LVWall,VentricularHCM,HOCMLVWall,VentricularHCM,HOCM肥厚阻塞性心6–10Normal正限制性3-5.0(5.5)DCM(Thin擴張性心肌病（壁薄Burnout燃盡性1.5-3.5LVWallThickness,左心室厚度Tip5thinkaboutTip5thinkaboutyourdifferentialsforleftventricularhypertrophy 甲 SystemicTip6:HCMTip:Tip6:HCMTip:asHCMmaybeuseECHO2D-measurements(notM-Papillary-muscleFocalGeneralized(concentric)HCM–?ConcentricLVHCM–?ConcentricLVAsymmetricseptalDilatedLA左心房擴SmallLVIntracardiac?????HCMFormsHCMHCMFormsHCM表現形WhyEchoisdifferentfrom PM-Diastole收縮WhyEchoisdifferentfrom PM-Diastole收縮 M-Diastole收 M-Systole舒張 [.71Autopsy尸 HCMEchoFeatures????LVHCMEchoFeatures????LVwallthickness≧6Greyzone:5.0(5.5)-6.05.0(5.5)6.0normalsystolicnormaltomildlydecreased??±LAdiastolicimpairmentwithdelayedrelaxationpatternordecreasedTVI-E-wave舒張受損，伴有延遲舒張模式或降低的組織速度超聲E+/-HCMwithSAMofthemitralvalve?Tip7:Tip7:Tip:measurein2D,freezeyourimageandscrollthroughcardiac技巧：用二維超聲測量，凍結圖像并緩慢移動光標查看心動周Measurements測量結Measurements測量結ScrollthroughyourEcho-loop,measureatseveraldifferentTip8:Tip8:PapillaryPapillarymusclesenlargementoftenthefirstabnormalitynotedsubjectivejudgment:normal,mild,moderate,lookforendsystolicchambermildormoderatepapillarymusclehypertrophy:calledequivocal–recheckafter3–6monthPapillarymuscle?Papillarymuscle?SeveralwaystomeasurepapillarymusclesMethodsnotyetclinicallyoftenLackofclearcut-off??PapillarymusclePapillarymusclePPMarea后乳區(qū)uppernormalcut-offvalueforsumofPPMPapillarymusclePapillarymusclehypertrophy:PPMPPMuppernormalcut-offvalueforlenghtofPPMPapillarymusclehypertrophy:Papillarymusclehypertrophy:PPMPPMuppernormalcut-offvalueforwidthofPPMLeftventricularexcludesystemicLeftventricularexcludesystemichypertensionhyperthyroidismScreeningformalecats>2公貓2femalecats:3-4Ifcatsareexaminedearlier,theyshouldbeTip9:Tip9:falseFalsetendonsaresometimescalled?moderatorHowever,moderatorbandsonlyexistin假腱有時被稱為“隔緣肉柱”，但是“隔緣肉柱”只存在于Tip9Tip9falsetendons假FalsetendonsarefoundinmanyOnlyoccasionallytheycauseTheycancausearestrictivepatternàdiastolicdysfunctionFalsetendonsmaynotberecognizedàandmaketheLVwalllookthick.SoquiteoftencatsareoverdiagnosedwithHCMduetofalsetendons“moderatorbandCM“moderatorbandCMCorrecttermsforfiberscrossingRV:moderatorband;LV:false?Pitfalls警Pitfalls警FalsetendonsmaymimicFalsetendonsFalsetendons假FalsetendonsFalsetendons假“falsetendonsCM“falsetendonsCMImportanttoslowtheEcholoop,orfreezetheimageandscrollthroughit!?Tip10:FreezeTip10:Freeze第10AsHRisoftenveryfastin因為貓的心跳一般很快Remembertousethe?Freeze“ButtonandscrollthroughtheimagesYoucanalsousethisbutton,iftheseesomethinginteresting,butcatmoves→→theloopisprobablyinthemachinesmemoryOrifyourEchomachinehasit:usethe?slowplay“functionforstoredloops????Tip11:mitralinflowTip11:mitralinflowUsetheECGtoidentifythewaves利用心電圖來確定??comesinearlydiastole–aftertheT-ontheE波出現在心舒期早期心電圖上的TA-wavecomesaftertheP-waveontheECG?Tip12:fusedTip12:fusedE-andA-RememberthatwithhighHeartratesEandA-wavesoftenfuse!??Tip13:DiseaseTip13:DiseaseVentriclegivesthediseasetheAtriashowtheclinicalimportanceoftheTherearenoestablishedvaluestogroupthecatsintodifferentseveritystages:somecardiologistsonlyusewalldiameterothersincludeLAsize?????HCMStagingLMU<<GreyzoneHCMStagingLMU<<Greyzone(weightdependant根據體重5.0–<6.0–<6.5–<6.0–1.5–>7.0>6.0>Fianal最后一TryFianal最后一TrytoexerciseyourEchoskillsfirstinOnceyougetyourviewsconsistently→→trya一旦你獲得的圖像穩(wěn)定→→嘗試對貓進行AndExercise,Exercise???RestrictiveRestrictiveRCMRCMissecondmostcommonRCMRCMissecondmostcommonformofcardiomyopathyincatsfeature:diastolicproblemcausedbystiffnessofmyocardialventricularwallsnotthickened心室壁不增normalcontractilitybutbothatriaenlarged!但兩個心房擴Restrictivecardiomyopathy限制性心肌MyokardialRestrictivecardiomyopathy限制性心肌MyokardialRCMRCMEndomyocardialFibrosisRestrictiveBothatriaVentriclesneitherRestrictiveBothatriaVentriclesneitherhypertrophied,norDiagnosisconfirmedbytissueDopplerimagingifnotavailable:Mitral-inflowRCMECHOFeatures????NormalLVwallnormalsystolicRCMECHOFeatures????NormalLVwallnormalsystolicbiatrialRestrictivefillingpatternofmitralinflow(E:A>2,shortdecelerationtime)二尖瓣流入限制性充盈表現（E:A>2，減速時間短RestrictiveTVIpattern(E-wave<2.5限制性組織速度圖譜(E-2.5Largefibroticbridgingbandorscarofthe±MildLVhypertrophy,severeLA???DopplerEchocardiography多普勒心DopplerEchocardiography多普勒心Trans-mitralInflowPatternsTissueDoppler??AVCAorticValveTissueDoppler??AVCAorticValveClosure主動脈瓣MVOMitralValveOpeningRestriktiveversusunclassifedRestriktiveversusunclassifedrestrictivecardiomyopathyshowssmallE-WavesinTDIRestrictiveRestrictiveRestrictiveRestrictiv