Severe CHF
Presentation
An 11 year old male neutered Yorkshire terrier presented for evaluation of coughing. The patient had a history of seizures that were controlled with Phenobarbital. He also had a several year history of a murmur. The coughing had been intermittent for several years as well but had progressively worsened in the 2-3 months prior to presentation. The coughing was described by the owners as hacking to honking with a terminal retch and did not appear to be associated with exercise or excitement.
Echocardiogram
Severe thickening of the mitral valve leaflets leading to severe regurgitation and moderate to severe left atrial enlargement. There was also mild to moderate dilation of the left ventricle with a mild decrease in pumping function.
Thoracic Radiographs
Marked collapse of the trachea in the caudal cervical region. There was also cardiomegaly (VHS 12.2) with moderate enlargement of the left atrium. Pulmonary vascular structures were mildly enlarged but no overt pulmonary edema was noted (Fig A).
Figure A: Right lateral thoracic radiographs taken on initial presentation. Not caudal cervical tracheal collapse, moderate cardiac enlargement (VHS 12.0) with no obvious pulmonary edema.
Tracheal Fluoroscopy
Grade III collapse of the trachea at the level of the thoracic inlet.
Diagnosis
Coughing secondary to tracheal collapse with stage B2 chronic valvular disease pending NT-proBNP
Treatment Pending NT-proBNP
Lomotile (1/4 tablet bid) was started as a cough suppressant as well as Azithromycin (10 mg/kg q 24hrs). The coughing did improve but the owners began to notice a decrease in activity as well as a mild increase in the resting respiratory rate.
NT-proBNP Results
6780 pmol/L suggesting that the coughing was due to cardiac disease.
Diagnosis post NT-proBNP
Coughing secondary to stage C2 chronic valvular disease with stage III tracheal collapse.
Treatment
Furosemide (2 mg/kg TID for 3 days then BID) was added which improved the patients’ activity, respiratory rate and greatly decreased the coughing. Pimobendan (1.25 mg PO BID) was also added at this time.
Re-Evaluation 2 Weeks Later
Marked clinical improvement with near complete resolution of the coughing. Benazepril (0.5 mg/kg PO BID) and an oral potassium supplement were added.
Follow-Up 8 Months Later
Patient continued to have frequent mild recurrent episodes of congestive heart failure every 6-8 weeks that responded to outpatient therapy of medication adjustments and additions. However, he developed severe recurrent congestive heart failure that required hospitalization ~ 8 months later (Fig B). His loop diuretic was switched from furosemide to Torsemide (Demodex) and he continued to do well for another 5 months before developing refractory congestive heart failure.
Figure B: Right lateral thoracic radiographs taken ~ 8 months after initial diagnoses of congestive heart failure secondary to chronic valvular disease. Note the extreme cardiac enlargement (VHS 13.5) as well as the severe pulmonary edema.