Echocardiography in sloth bear (Melursus ursinus)

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Abstract Echocardiography is the accepted term for the study of cardiac ultrasound. It is a technique by which we can do the imaging of the heart with the help of ultrasonography machine with a suitable probe. These techniques provide valuable diagnostic information without risk to the patient as it is a non-invasive procedure. The M-mode, two-dimensional (2D mode), and Doppler mode are maximum practiced techniques in echocardiography. Since there is no need of anaesthesia and special restraining procedure, the echocardiography is well developed and has become an integral part of cardiac evaluation of humans, small animal practices and reptile medicine especially in ophidian as well. But due to the huge body size and need of special restraining procedure with anaesthesia this technique is not established enough in wildlife practice particularly in sloth bear that belongs to ursidae family. The objective of this study is to develop the procedure for assessment of optimal approaches of echocardiography in sloth bears such as instrument selection, patient preparation and positioning etc and establish a cardiac image catalogue. This will help to identify the normal echo-anatomy of the heart and possible measurements B mode and M mode for further evaluation of the normal echocardial anatomy and colour flow Doppler to understand the normal blood inflow and outflow of heart. Keywords: Echocardiography, Heart, Sloth bear, B-mode, M-mode, Doppler mode, Ultrasonography

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4   International Journal of Veterinary Sciences and Animal Husbandry 2017 24: 04-09  ISSN: 2456-2912 VET 2017 24: 04-09 © 2017 VET www.veterinarypaper.com Received: 05-05-2017 Accepted: 06-06-2017 Ilayaraja Selvaraj Deputy Director veterinary services Wildlife SOS New Delhi Delhi India. Arun A Sha Director Veterinary research Wildlife SOS New Delhi Delhi India Puspendra K Singh Junior veterinary Officer Wildlife SOS New Delhi Delhi India Correspondence Arun A Sha Director Veterinary research Wildlife SOS New Delhi Delhi India Echocardiography in sloth bear Melursus ursinus - A preliminary approach Ilayaraja Selvaraj Arun A Sha and Puspendra K Singh Abstract Echocardiography is the accepted term for the study of cardiac ultrasound. It is a technique by which we can do the imaging of the heart with the help of ultrasonography machine with a suitable probe. These techniques provide valuable diagnostic information without risk to the patient as it is a non-invasive procedure. The M-mode two-dimensional 2D mode and Doppler mode are maximum practiced techniques in echocardiography. Since there is no need of anaesthesia and special restraining procedure the echocardiography is well developed and has become an integral part of cardiac evaluation of humans small animal practices and reptile medicine especially in ophidian as well. But due to the huge body size and need of special restraining procedure with anaesthesia this technique is not established enough in wildlife practice particularly in sloth bear that belongs to ursidae family. The objective of this study is to develop the procedure for assessment of optimal approaches of echocardiography in sloth bears such as instrument selection patient preparation and positioning etc and establish a cardiac image catalogue. This will help to identify the normal echo-anatomy of the heart and possible measurements B mode and M mode for further evaluation of the normal echocardial anatomy and colour flow Doppler to understand the normal blood inflow and outflow of heart. Keywords: Echocardiography Heart Sloth bear B-mode M-mode Doppler mode Ultrasonography 1. Introduction The use of ultrasound in veterinary medicine is widespread as a diagnostic supplement in the clinical routine of small animals but there are few reports in wild animals 6 12 . It is a non- invasive approach for exploration of morphology topographic anatomy and biological process in Non-domestic animals 13 . This imaging technique is still underutilised in wildlife medicine due to the limited knowledge of the topography and ultrasound anatomy of their organs and also the need for anaesthesia with special restraining procedure 12 . According to individual anatomical structure in different vertebrate taxa use of ultrasonography is combined with the characteristic feature for applying this imaging technique 13 . Advanced progress of imaging modality in veterinary sciences is being improved in ultrasound technology through the development of new types of probes for different applications such as cardiovascular abdominal and intra cavity ultrasonography scanning. Echocardiography is the accepted term for the study of cardiac ultrasound. Echocardiography uses sound waves in the order of frequency of greater than 20000 Hz. Piezoelectric crystals in the form of a transducer emit ultrasonic waves at high frequency when subjected to an alternating current. This same transducer receives the reflected waves and forwards them to be electronically processed and displayed for interpretation via one of three modes such as B-mode M-mode and Doppler mode 3 . Echocardiography is a safe 1 8 non-invasive method that provides quantitative information of cardiac wall thicknesses internal cavity dimensions valve motion ventricular function and the presence or absence of intra cardiac structures 4 5 7 . The objective of this study is to develop the procedure for assessment of optimal approaches of echocardiography in sloth bears and establish a cardiac image catalogue for further feature study reference. Since the Agra bear rescue facility is a life time care and rehabilitation centre for the rescued dancing sloth bears which have come from poor health background 10 the initial and periodic health screening by adopting recent technique is more necessary to keep them in a comfortable healthy status and to establish preventive health care protocols.

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5   International Journal of Veterinary Sciences and Animal Husbandry 2. Materials and method Since ultrasound propagates poorly through gaseous or bony media an area free of lung interface must therefore be determined to achieve a proper cardiac imaging. Proper patient preparation and positioning examination table selection selection of suitable ultrasonography machine with required probe/transducer and knowledge of the sonographer regarding the different modes of ultrasonography along with basic organ anatomy and its topography within the body cavity Fig.1 of the animal patient are major factors which influence the efficient echocardiographic examination in the desired animals. 2.1 Patient preparation and positioning For getting good cardiac image the patient needs to be stationary in position and the transducer needs to be in contact with the animal’s skin as close as it can be without air pockets in between the transducer and skin. This can be achieved by chemical immobilization of the bear and clip or shave the hair on the intercostal region where we can recognise the apical beat then clean thoroughly eliminate the skin debris and dirt if any otherwise it may cause poor image quality by causing hindrance to the ultrasound beam penetration. The bear was tranquilized as per the standard protocol with Injection Xylazine 2 mg/kg and Injection Ketamine 5 mg/kg intramuscularly using blow pipe 11 . Both left and right side hemithorax region clipped and cleaned thoroughly and the coupling gel is applied on the scanning area 5 minutes prior to start the examination to allow the gel to soak the skin tissue and avoid air pockets. This will enhance the penetration of ultrasound beam and produce good quality image. The bear was kept in right lateral recumbency and the right forelimb gently pulled and kept cranially Fig.2. The same was followed for left forelimb while positioning the bear in left lateral recumbency. 2.2 Equipment selection Sloth bears have body weights ranging between of 60 – 120kg. The patient’s examination table needs to be selected accordingly to bear’s weight without compromising and also it should possess the facility to reach the animal’s hemithorax region with the scanning probe without any difficulties to the operator and bending the probe cable as well. We specially designed the examination table for this procedure in such a way to full fill the above said requirements Fig.3. Any ultrasound machine with cardiac package and Transducer with small foot print can be used for Echochocardiographic studies as like in medical and small animal veterinary practices. We used LOGIQ e manufactured by GE healthcare company and Phased array transducer model 3S-RS. 2.3 Organ anatomy As like other mammalian species sloth bears also possess the well-developed 4 chambered heart with valves in the mediastinal cavity. The cardio vascular system has resemblance as close as to humans and canines so we followed the echo cardiographic studies as described by the previous authors in mammalian species especially in dogs. We performed right parasternal long Fig. 4 and short axis Fig. 5 left apical parasternal location Fig 6 views along with M mode Fig.7 and Doppler mode Fig.8 9 recorded the images 14 . Fig 1: Radiograph showing location of heart inside the thoracic cavity of a normal sloth bear. Fig 2: The bear kept in right lateral recumbency and the right forelimb gently pulled and kept cranially on the examination table after clipped the hair

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6   International Journal of Veterinary Sciences and Animal Husbandry Fig 3: Echocardiography examination table model. Fig 4: Right parasternal long axis view Fig 5: Right parasternal short axis views

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7   International Journal of Veterinary Sciences and Animal Husbandry Fig 6: Left parasternal apical four two chamber view Fig 7: M mode view for mitral valve activity left ventricle Fig 8: Colour Doppler mode showing left ventricle blood flow Fig 9: Pulsed wave Doppler- Mitral valve and Aortic valve activity

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8   International Journal of Veterinary Sciences and Animal Husbandry 2.4 Types of echo Display Modes There are three basic modes to consider in Echocardiography for complete evaluation of heart anatomy and its functions effectively. B ‐mode or brightness is the electronic conversion of the A ‐mode and A ‐line information into brightness ‐modulated dots on a display screen. The brightness of the dot is proportional to the echo signal amplitude 9 . The B ‐mode display is used for M ‐mode and 2D gray ‐scale imaging. This gives good cross-sectional images of the heart and is useful to identify conditions such as pericardial effusion chamber enlargement and valvular disease. M ‐mode M for motion is a technique that uses B ‐mode information to display the echoes from a moving organ such as the myocardium and valve leaflets from a fixed transducer position and beam direction on the patient. The echo data from a single ultrasound beam passing through moving anatomy is acquired and displayed as a function of time represented by reflector depth on the vertical axis beam path direction and time on the horizontal axis. Since M ‐mode can provide excellent temporal resolution of motion patterns it is used to evaluate chamber size and contractility as well as indices of cardiac function. Doppler mode consists of four types of Doppler ultrasound which rely on the change in frequency of returning echoes depending on whether flow is towards or away from the transducer. Pulsed wave Doppler PWD – ‘gates’ identifies the specific sampling area e.g. across the mitral valve. Unfortunately PW cannot calculate high velocities due to a phenomenon called ‘aliasing’. Continuous wave Doppler CWD – can identify high velocity but the exact location of the flow cannot be identified. Colour flow Doppler CFD – provides an easy visual identification of flow direction and velocity by producing red and blue coloration 9 . It can be remembered as BART blue away red towards. Colour Doppler is angle dependent so that no Doppler shift is recorded when blood flow is 90 degrees to the transducer. The combination of all three types of Doppler is used in practice as per the need or as a routine examination procedure. Power Doppler PD detects very-low-velocity blood flow and small blood vessels. It is not prone to ‘aliasing’ artifact as it is essentially angle independent 2 9 . 3. Result and Discussion The right parasternal long axis is the best view for visualising left ventricle LV apex mitral valve MV LV out flow tract LV O aortic valve AV proximal ascending aorta left atrium and interventricular septum. The right parasternal short axis is the suitable view for LV apex high papillary muscle level chordae tendineae of the LV mitral valve MV aortic valve pulmonary arteries and pulmonic valve. Left parasternal apical long axis will help us to see the LV MV and left atrium LA with slight anticlockwise rotation the LV O can be seen. Left cranial parasternal location short axis view at the level of the aortic root provides the right ventricular inflow and outflow tracts clearly. However we followed the previous author’s recommendation we did necessary fine adjustments of transducer position and angulation and image plane orientation in sloth bears to obtain optimal cardiac images. Since the transducer movement and angulation is too sensitive we can’t achieve proper echocardiography in sloth bear without sedation. This image modality would be helpful to carryout efficient diagnosis of the cardiac problems such as pericardial effusion dilated cardiomyopathy and degenerative valve disease efficiently in sloth bears. 4. Conclusion Since echocardiography is a non-invasive and risk free technique and provides a wealth of data concerning cardiac morphology and function it has to be an integral part of health examination in sloth bears and other captive wild animals as well. Adaptation of this procedure and images should facilitate consistent performance and provide basic information for further studies in future. It should always be borne in mind that echocardiography is a specialist area requiring a thorough knowledge of cardiac anatomy and pathophysiology. Referral to a cardiologist should be considered if it is an option and is a useful way of learning. 5. Acknowledgement: We are sincerely thanking to BCF Technology and Dr. Nicolette Hayward for the generous donation of cardiac probe. We appreciate the great active effort of Ms. Tracianna Morrell Myers. Australia for the donation of Ultra- sonography machine. We are grateful to Mr. Kartick Satyanarayan Geeta Sheshmani Co-Founders Wildlife SOS for their tire less support and all our animal care staff of wildlife SOS India. 6. Reference 1. Baker ML GV. Dalrymple. Biological effects of diagnostic ultrasound. A Review. Radiology. 1978 126:479-483. 2. Boote EJ. AAPM/RSNA physics tutorial for residents: topics in US: Doppler US techniques: concepts of blood flow detection and flow dynamics Radiographics. 2003 23:1315. 3. Allen DG. Echocardiography as a Research and Clinical Tool in Veterinary Medicine Can. Vet. J. 19822 3:313- 316. 4. Feigenbaum H. Echocardiography 2nd Edition. Philadelphia: Lea Febiger 1976 1-340. 5. Fortuin NJ Hood WP Craige E. Evaluation of left ventricular function by echocardiography. Circulation 1972 46:26-35. 6. Göritz F Hildebrandt T Jewgenow K Wagner N Hermes R Strauss G et al. Transrectal ultrasonographic examination of the female urogenital tract in nonpregnant and pregnant captive bears Ursidae. J Reprod Fertil Suppl. 1997 51:303-12 7. Gutgesell HP Paquet M Duff DF McNamar DG. Evaluation of left ventricular size ad function by echocardiography. Results in normal children. Circulation. 1977 56:457-462. 8. Kirk. Bistner’s. Hand book of Veterinary Procedures and Emergency Treatment 7 th Edition. W.B. Saunders company Philadelphia. 1995 311-313. 9. Kremkau FW. sonography:principles and instruments ed 8 St.LouisElsevier Saunders. 2011 1369:127-176. 10. Milella L. Dental disease in rescued dancing bears. Companion Animal 2007 12:75-79. 11. Page CD. Sloth bear immobilization with ketamine- xylazine combination: Reversal with yohimbine. Journal of the American Veterinary Medical Association. 1986 189:1050-1051. 12. Rejane Ribeiro G Ana Paula Costa A Nathália Bragato Angela Fonseca M Juan Duque CM. Tales D Prado Andrea CR Silva and Naida C Borges. Normal

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9   International Journal of Veterinary Sciences and Animal Husbandry sonographic anatomy of the abdomen of coatis Nasua nasua Linnaeus 1766. BMC Veterinary Research 2013 9:124. 13. Thomas Hildebrandt B Frank Göritz Robert Hermes Fritsch Guido. Ultrasonographic Techniques Applied to Non-Domestic Species. Ultrasound. 2002 102:7-14. 14. Thomas WP Gaber CE Jacobs GJ Kaplan PM Lombard CW Moise NS et al. Recommendation for standards in transthoracic two- dimensional echocardiography in the dog and cat. J. Vet. Intern. Med. 1993 7:247-252.

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