Shinzō VetCardio

01/01/2024

Why is medicine an art?

Because sometimes test kits may show false negative result (negative reaction despite having true infection) and clinicians have to make careful interpretation.

In this video, the test kit showed a negative reaction for canine heartworm. However, structures resemble heartworms were seen within the severely dilated right atrium.

Shockingly, there was a positive reaction for Ehrlichia species as an incidental finding.

为什么医学是门艺术？

因为有时检测仪可能会显示假阴性，所以兽医必须小心解读结果。

在这段视频中，检测仪显示犬心丝虫的阴性反应。然而，在严重扩张的右心房内可以看到类似于心丝虫的结构。

意外发现是，检测仪对埃立克体属显阳性反应。

#兽医 #心丝虫 #宠物

26/12/2023

Very rarely, left atrium may rupture resulting in pericardial effusion. The asterisks indicate dilated left atrial appendage where the tear was suspected.

极少数的情况下，左心房可能破裂导致心包积液。星号表示疑似撕裂的左心耳。

18/12/2023

Research brings veterinary medicine to another level for betterment of animals.

17/12/2023

As the only non-Japanese participant, I presented a clinical case, in the Japanese language, on “use of mesenchymal stem cell for treatment of pulmonary hypertension secondary to myxomatous mitral valve disease in two dogs” in Japanese Veterinary Society of Veterinary Cardiology Annual Meeting, on 17/12/23.

I’m glad to receive good responses from the audience where I answered 5 questions (although a few questions were not answered given limited time) during the Q&A session.

Such meeting where Japanese cardiologists get together (that’s not available in Malaysia) is really valuable to provide new stimuli and challenging ideas for further advancement of veterinary cardiology.

10/12/2023

I’ll be away from 14-19 Dec 2023 to present a clinical case in Japanese Veterinary Cardiology Annual Meeting, with title as such:

"Efficacy of adipose-derived mesenchymal stem cells on clinical findings and hemodynamics in 2 dogs with pulmonary hypertension secondary to MMVD"

I’ll be back to see cases on 20/12/23.

04/12/2023

Many pet owners including veterinarians are very concerned about their pet’s renal functions, more especially if their pet has to take a diuretic agent to treat heart failure.

This example shows a real situation of how “no diuretic” actually worsened the renal function (cardiorenal syndrome).

The dog was initially treated with pimobendan, furosemide, and spironolactone medications for left heart failure due to MMVD. Both the furosemide and spironolacfone medications were discontinued as preceding veterinarian saw increased renal readings.

After 5 months, the dog came back with a relapsed heart failure and an increased SDMA level (SDMA is a marker for renal function). Torasemide, a potent diuretic agent was started. The renal parameters were slightly reduced after one month, from 31 to 26) despite diuretic therapy.

Next, spironolactone, a mild diuretic was re-added, and the renal readings decreased subsequently. Now, the SDMA and creatinine levels are only mildly increased although the dog is getting two diuretics at once.

Indeed, management of heart failure in pets is challenging. Determining the “just-right effective dosage” is an art in veterinary cardiology.

许多宠物主人包括兽医非常关注宠物的肾功能，尤其是如果他们的宠物必须服用利尿剂治疗心力衰竭。

这例子告诉我们“没有利尿剂”或可恶化肾功能的真实情况。

该犬最初接受匹莫苯丹、利尿剂和螺内酯药物以治疗 MMVD 引起的左心衰竭。之后因为家庭兽医发现肾指数增加，于是停用了利尿剂和螺内酯药物。

5 个月后，复诊时发现该犬复发肺水肿，并且SDMA水平升高（SDMA 是肾功能的标志物）。 服用Torasemide一种强效利尿剂的 1个月后，其肾指数的SDMA从31微降至26。

一个月后，重新添加螺内酯药物，犬的肾脏指数继续下降。目前，即使同时服用两个利尿剂，它的SDMA和肌酐水平仅轻度升高。

事实上，宠物心力衰竭的治疗具有挑战性。 如何断定“恰到好处的有效剂量”，是兽医心脏病学的一门艺术。

02/12/2023

Meet Elvis, a Doberman which was treated with pimobendan for years. I saw him a few months back and stopped the medication. Now after 3 months of medication cessation, findings suggestive of dilated cardiomyopathy (DCM) are still not observed. So, he doesn’t need to take the heart medication anymore.

DCM is a heart muscle disease which is progressive in nature, that means, the heart muscle weakens and loses function with time. Although Dobeman is predisposed to the DCM, it doesn’t mean that all Doberman dogs will get the disease.

While it’s challenging to diagnose asymptomatic DCM, an annual cardiac exam is recommended should you have a Doberman dog.

24/11/2023

Another sporadic case of double-chambered right ventricle (DCRV) in a cat presented with pleural effusion.

There’s a fibromuscular band in the right ventricle, which divides the right ventricle into 2 sub-chambers. This band causes severe obstruction to the blood flow into and out of right ventricle.

DCRV is a congenital disease, which doesn’t respond so well to interventional treatment (balloon valvuloplasty). An open heart surgery to excise the band is curative but not available locally.

22/11/2023

ACVIM classification of feline cardiomyopathies
美国兽医内科医学院猫心脏病的临床分期

20/11/2023

Sometimes, I am presented with cats with “pericardial effusion” detected by preceding vets. The cats are otherwise healthy, so presence of the pericardial effusion is questionable.

One explanation is, epicardial fat-pad (a fat layer around the heart) is mistakenly perceived as pericardial effusion.

In the video, the epicardial fat pad is depicted by asterisks.

有时候猫咪因怀疑有心囊积水和心脏病来给我做详细检查。但是它们表面上看起来健康而无症状。

理由很简单：它们并没有心囊积水，只是心外膜脂肪看起来像心囊积水。

心外膜脂肪是指位于心肌表面和心外膜内脏层之间的脂肪组织。

视频中的星号显示心外膜脂肪。

17/11/2023

What is the unusual “bulge” on the chest X-ray?

To answer that question, the dog was presented for further investigation.

Differentials include enlarged pulmonary veins (pulmonary edema) and enlarged mediastinal lymph node. However, there were also concurrent venous pattern (indicating pulmonary venous congestion) and heart enlargement so the former differential was more likely.

On echocardiogram, the bulge was seen as a dilated pulmonary vein, confirming the diagnosis.

12/11/2023

Similar to human beings, obese pets have a greater risk for cardiovascular morbidity and mortality too.

These echocardiography images were taken from an obese golden retriever (38kg). Abnormal findings included left ventricular wall thickening (especially septum) and impaired relaxation (indicating diastolic dysfunction) as well as increased left ventricular outflow tract velocities.

In one study, obese pets also live shorter than lean pets!

So, how "lean" is your pet?

宠物和我们一样，若是肥胖患心脏病的风险更大。

一只体重达38公斤的金毛猎犬的超声心动图图像当中的异常所见包括左心室壁增厚（尤其是隔膜）和舒张功能障碍以及左心室流出道速度增加。

另外，在一项研究中，肥胖的宠物也比正常体重的宠物活得更短！

那你的宠物有多“苗条”呢？

Last image credit to Royal Canin

06/11/2023

As a small animal veterinarian, I am proud to be a member of the wildlife team to perform cardiac examination on Borneo sunbears and contribute to wildlife medicine, pro bono.

It’s an eye-opening experience where “team-work” to ensure “safety” of both team members and animals is of utmost importance.

虽然我是小动物兽医，但很荣幸能成为野生动物兽医团队队员之一，义务检查婆罗洲马来熊的心脏，为马来西亚野生动物学出一分力。

与宠物不同，检查野生动物时非常注重团队合作和协调以确保团员和动物的安全，让我大开眼界。

01/11/2023

Two days after the PDA ligation surgery, the heart enlargement was much reduced. However, normalization of heart chambers and functions size aka “reversed remodeling” usually takes a few months.

PDA手术的2天后，心脏明显缩小。
一般上，心脏需要几个月的时间才能渐渐回复正常。

Video about the case: https://fb.watch/o1WavygBAc/

29/10/2023

A Pomeranian pup was presented with pulmonary edema (heart failure) due to hemodynamically significant left-to-right shunting patent ductus arteriosus (PDA).

PDA is a congenital heart disease where the pathway between aorta and pulmonary artery fails to close after birth, which results in heart dilations. A pup with a medium to large PDA usually doesn’t survive 1 year of age.

Despite a high risk for anesthesia, our anaesthesia team did an exorbitantly excellent job to stabilize and maintain its vital signs to allow successful ligation of the PDA.

区区14周大的博美犬因动脉导管未闭(PDA)罹患肺水肿。

PDA是指大动脉和肺动脉之间的管道在宠物出生后没有自然关闭。它是先天性心脏病之一，一般上很少狗狗能够活到一岁。

虽然麻醉风险极高，在麻醉团队的出色配合下，手术顺利完毕。

25/10/2023

A diagrammatic explanation on “systolic anterior motion”, aka SAM.

SAM is observed more commonly in cats. Why?

19/10/2023

A dog with treated chronic hypertension showed obvious left atrioventricular dysfunction on strain analysis, which is a newer and more robust echocardiography tool.

On conventional echocardiogram, the left ventricular motion was slightly sluggish; the EF and FS readings (systolic function indices) were mildly decreased.

It’s speculated that myocardial fibrosis, which is a common sequela in hypertension, had caused heart muscle stiffness and the abnormal echocardiogram findings.

虽然长期服药后高血压受到控制，狗狗的左心功能在斑点追踪超声心动图中呈现明显障碍。（斑点追踪超声心动图是较新的心脏检查工具。）

在一般的超声心动图上，左心室运动略微缓慢；EF和FS为收缩功能指数也轻度下降。

心肌纤维化是高血压的常见后遗症，导致心肌僵硬和超声心动图异常。

10/10/2023

Bullseye Strain from two dogs. The bullseye plot allows us to know how well segments of the left ventricle contact.

First pic was taken from a dog with a mild MMVD. The global strain rate was -21.4%.

Second pic was taken from a dog showing myocardial dysfunction with a reduced strain rate of -10.3%, and also a low QRS voltage on ECG.

Besides, from the second pic, we can also see uneven color distributions depicted as red (normal), pink (hypokinetic), and blue (dyskinetic) shades.

什么是应变超声心动图？

它可让心脏科医生清楚知道宠物心脏（特别是左心室）每个部分的实际功能。

图1- 罹患轻微二尖瓣膜病的狗
图2- 心脏功能疑受损的狗

与图1不同的是，从图2中我们可看到不同颜色区域，分为红，粉红和蓝色，意味着心脏每个部分有着参差不齐的功能。

#兽医心脏科 #心超 #宠物心脏检查 #应变超声心动图 #兽医心脏科 #心超 #宠物心脏检查 #应变超声心动图

22/09/2023

As cardiac diet for dogs with heart failure is currently unavailable in Malaysia, many dog owners have been asking me about an alternative.

Diet which resembles more closely to the cardiac diet is “renal diet”. However, as its name suggests, it’s specially formulated to cater dogs with a kidney disease. Both diets differ in nutrient contents.

For instance:
Protein level is higher in the cardiac diet
Sodium level is lower in the cardiac diet

Despite so, until the cardiac diet becomes available again, the renal diet is recommended, inevitably, in which SOME dietary modifications are necessary.

Note that not all dogs need a prescription diet!

Talk to your veterinarian to formulate a solution.

由于目前马来西亚缺乏犬用心脏病处方饲料，许多狗主人焦虑，询问替代方案。

与犬用心脏病处方饲料更相似的饲料是“肾脏病处方饲料”。然而，顾名思义，它是专门为患有肾脏疾病的狗狗而配制的。

这两种饮食的营养成分不同。

犬用心脏病处方饲料含有较高的蛋白质和较低的钠含量。

所以，在犬用心脏病处方饲料再次在大马面世前，狗主可以考虑“肾脏病处方饲料”，但是当中的一些饮食调整是必要的。

切记，并非所有的狗都需要处方饲料！
所以请与您的兽医洽谈。

16/09/2023

Recently I attended to a dog which came in for a 6-month review for stage C MMVD (heart failure) diagnosed in Jan 2023.

I was shocked to learn that diuretic medication was discontinued because the dog showed increased renal parameters.

Let me share some clinical findings:

1. The dog was breathing quite rapidly, with some abdominal effort.
2. The X-ray showed a severely enlarged heart with perihilar opacity and interstitial pattern (edema).
3. Though the diuretic medication was ceased for months, the renal parameters (SDMA and creatinine) were still elevated [Cardiorenal syndrome likely, due to poor heart function).
4. From sleeping respiratory rate (SRR) graph, the readings were not stable.

Diuretic remains the cornerstone treatment for heart failure. Cessation of the diuretic medication is therefore NOT recommended. In this context, we should taper the diuretic to the lowest effective dose to make both the heart and kidneys “happy”, which is often a challenging “art” in veterinary cardiology.

Use diuretic when necessary; do not stop it when it’s clearly indicated.

前几天来了一只狗狗做心脏复检。它于2023年1月罹患第C期MMVD（心力衰歇）。

我很震惊地得知它没有服用利尿剂。询问之下，这是因为狗狗的肾指数上升其兽医建议停药。

让我分享检查结果：

1. 狗的呼吸急促和用力。
2. X线片显示心脏严重肿大和肺水肿。
3. 虽然停了利尿剂数月，但肾指数的SDMA和肌酐仍然超出标准值。这可能是意味心肾综合征，也就是说心脏功能差导致肾功能下降。
4. 从睡眠呼吸频率（SRR）图来看，读数不稳定。

利尿剂是治疗心力衰竭里最重要的药物，所以不建议随便停药。反之，要如何逐渐减至最低有效剂量，以使心脏和肾脏都“快乐”，是兽医心脏病学中具有挑战性的“大学问”。

利尿剂，
当有治疗指征时，不要停止它。
没有治疗指征时，请别滥用它。

14/09/2023

Calling for pet owners to join us in an online sharing session on 21/9/23 at 8pm!

In conjunction with Heart Awareness Month, we are going to talk about the frustrating "coughing" in pets!

https://www.oyen.my/post/understanding-coughing-in-cats-and-dogs

Oyen Insurance - Pet & Travel

One significant concern is the connection between coughing, respiratory disease, and heart disease in cats and dogs. Here's what every pet parent should know:

05/09/2023

Not all cases coming to me eventually require an echocardiogram (heart ultrasound).

Physical examination and chest radiography should precede every echocardiogram to determine an indication.

In this case, the dog has a low-grade heart murmur (grade 2/6) and a normal heart size on chest radiography (VHS

27/08/2023

Severe pulmonary hypertension caused by heartworm infection in a dog.

Echocardiography findings:
✅ Lung pressure during systole was 113mmHg (normal is less than 30)
✅ Pulmonary artery was dilated and showed mid-systolic notch on outflow velocity.
✅ Within the right pulmonary artery, heartworm was seen.

You don’t need many heartworms to cause severe pathology and pulmonary hypertension.

因犬心丝虫病引起的严重肺动脉高压

超声心动图检查结果如下：
✅ 收缩期肺动脉压为113mmHg（正常小于30）
✅ 肺动脉扩张，前向血流频谱收缩中期出现切迹。
✅ 在右肺动脉内可看到心丝虫物体。

区区一只心丝虫足以导致严重病理和肺动脉高压。

10/08/2023

[Hiring]

I am looking for a veterinary assistant (full-time or part-time) to assist in cardiology consultation with following criteria:

1. Be able to communicate adequately with pet owners
2. Pet-oriented person - is not afraid of cats & dogs; not allergic to animal hair, etc
3. Good physical condition - able to handle and restrain wiggly animals of 3-40kg
4. Language - English and Malay, being able to speak Mandarin is an advantage

If interested, please drop a message.

07/08/2023

https://www.thestar.com.my/opinion/letters/2023/08/07/a-toast-to-busy-vets-everywhere

WHEN we are sick, we go to a clinic. Despite long queues, despite tardy specialists, we wait patiently. We have no choice.

In the consultation room, we have a mere handful of minutes to talk to the doctor. “You have a fever, probably due to viral infection. Take these medications.” If it’s a busy specialist, we probably have only a few words with him. “How are you feeling? Good? OK, I’ll see you then.”

We go home, we follow instructions and take medications without knowing what they are and do to our body. If we don’t get better, we visit the clinic again.

When a dog or cat is sick, its owner takes it to a veterinary clinic. If the queue is long, the receptionist gets the blame.

In the examination room, the veterinarian spends 30 to 60 minutes per consultation and is expected to answer every single question like a walking Wikipedia. The vet may need to pause the consultation when the owner is busy messaging or answering phone calls.

The vet is obliged to recount every clinical finding, trivial to serious, with proof and evidence to the owner. “Differentials for low red cells are....” “Causes of the cough are....”

Then he prescribes medications and, naturally, states all their indications and side effects: “Theophylline is prescribed to reduce coughing and may cause restlessness and tachycardia.”

That’s not the end.

The veterinarian is expected to answer questions texted to him or her for free, round the clock. At times the messages come in at 10pm or 11pm. “Why is my Suki not eating/vomiting/coughing?” “Is this a supplement or diet recommended?” The busy vet also answers questions when he is chewing his lunch, with photos of slimy puke or watery stools to spice up his repast.

If the vet is slow to reply or even – gasp! – ignores messages, he gets a lengthy bad review on social media. Some pet owners may even lodge a complaint with the Malaysian Veterinary Council.

Companion veterinarians are sturdy, aren’t they?

DR ANTHONY LEONG ZI PING
DVM (Doctor of Veterinary Medicine) & PhD
Kuala Lumpur

FROM DVM (Doctor of Veterinary Medicine) & PhD Kuala Lumpur

05/08/2023

I was harassed by this dog client, until I had to leave the hospital and seek protection at a nearby police station.

The police report is self explanatory.

Stop harassment to veterinarians!

I won't hesitate to take legal action should defamation arise due to this matter.

27/07/2023

Pericardiocentesis is a procedure to remove fluid from pericardial sac to aid diagnosis and even save life!

When the pericardial fluid builds up too much or fast, it compromises right cardiac output, resulting in weakness, fainting, and even death.

Removing even a tiny bit of fluid can make a big difference to improve the right heart function.

Causes of pericardial effusion include cancer, inflammation of pericardial sac (pericarditis), and right heart failure.

In this dog, highly dividing cancerous cells were seen from the pericardial fluid.

心包穿刺借助穿刺针直接刺入心包腔，从心包囊中取出液体。这是用于帮助诊断甚至是可救命的措施。

当心包囊积液过多或过快时，会影响右心输出量导致虚弱、昏厥甚至死亡。

即使去除少量心包囊液体也可以大幅度改善右心脏功能。

心包积液的原因包括肿瘤，心包囊炎和右心衰竭。

这只狗的心包液中出现高度分裂的癌细胞。

24/07/2023

On 7/7/23, I was honored to be invited by Royal Canin Malaysia to share some clinical cases to fellow veterinarians in MSAVA Pre-Congress Dinner Symposium.

According to the organizer, about 400 participants attended the event, physically and virtually. Some were from Indonesia and the Philippines.

Although it was just a short session, I hoped that I delivered an important message to fellow veterinarians, that’s, to “think out of the box” and always consider extra-cardiac factors which may affect the cardiovascular health.

15/07/2023

Stitch was back for a review for stage C MMVD. He was diagnosed with heart failure 17 months ago. Since then, he has been taking several medications to control his vital functions.

He is indeed a cute and strong dog and blessed with tonnes of love from his owners.

While most dogs survive for less than 1 year after succumbing to heart failure, he shows that miracle does exist with early detection and treatment. His owners have been so compliant not to miss any medications and review examinations.

我首次见Stitch是在2022年2月15日。它因为二尖瓣膜关闭不全病而罹患肺水肿。之后，主人都很听话带它复诊来调药和定时喂药。

14/7/23的复诊Stitch看起来还是很健康和顽皮。由于犬罹患心力衰歇的平均寿命是约1年左右，能够再次看到Stitch我感到很安慰。

08/07/2023

A cat had heart failure last year. Now, his heart is normalized remarkably.

Although uncommon, reversal of heart muscle thickening is possible. This is known as “transient myocardial thickening” or “transient myocarditis”.

去年，猫咪罹患心源性肺水肿。现在，心脏几乎回复正常。
这现象称为“短暂性心肌肥厚病”。