147 Heart murmurs in puppies

Good day Jasmine Barfield here and this is the RVC clinic podcast. Thank you for listening, thank you for subscribing on your smartphone or generic fruit based device. We really are grateful for you taking the time to download and listen to this podcast. We do not ask for much in return that we would be incredibly grateful if you could pop to Apple podcast Spotify or a cast and leave us another out of you. Obviously a five star of you would be great. We really appreciate if you could take a couple of minutes of your time and leave us a review. Thank you and for those you might be listening to a different sort of style of of entry. The reason why that's better is because Brian keeps on complaining that I just ramble through that and you can't actually understand any word that I'm saying. But anyway we'll move on. Today joining Brian and myself in our actual physical studio, we're going to talk to Nikessa Mori, one of our cardiologists here at the RVC. It's one of our lecturers in the cardiology here at RVC and we thought we'd have a chat about murmurs in puppies. So thank you very much Nikessa for joining us. Thank you so much. It's great to be here and to chat about this interesting topic. Thank you. Maybe we should start about at what point in time would you say that a puppy has a murmur that's not necessary that's going to be something that will last if that makes sense. So are all puppies when they're born? Would you normally hear a murmur? Yeah that's a really good question and you know it can be very variable depending on the congenital disease process that a puppy is born with. So as an example if we have valvula, pulmonic stenosis, we know those patients are going to have a murmur right from the very start. Whereas if we think about something like valvula aortic stenosis, whilst most of those puppies will still come in at their wellness examination and have a murmur, we know that that disease process does generally tend to get worse as they grow to fill to being fully grown and so in those instances their murmurs potentially could become louder or they could change over time. So for me I think the most important thing is that when we have our puppies presenting for their initial wellness examinations when they're coming in for vaccinations, that really is the initial time to start listening to their heart, start listening to different locations and noting any subtle changes. And if they then come back for their final set of vaccinations and the murmurs still persists, those are timeframes to say well hey do we need to potentially get in contact with a cardiologist or a set holder to try and screen to work out if there is something potentially more concerning rather than just a typical physiologic puppy murmur. Again is it maybe with that in mind? So why do puppies get murmurs? What is a normal physiological murmur? Why does that occur? Yeah again another good question because I think it's something that easily a lot of people potentially forget is that when animals are young they have something what we call altered rheology which is basically just referring to the speed at which blood is going to flow through certain vessels, the way that things like resistance are going to potentially impact their vessels and as a result of that they could have a change in speed of their blood flow out of their heart and as a result of that we can then potentially pick it up on oscultation. Another thing that potentially is influenced by that is we know most puppies are going to have a lower or decreased red blood cell count and that also potentially could exacerbate the speed at which blood flow leaves their heart. So that's one of the first things you know that we will commonly kind of think of but it's obviously it's very different to having congenital disease. So congenital disease is essentially that an animal is born with a problem associated with their heart. It's something that embryologically went wrong and the kind of more common disease processes that we're going to see are going to include things like left to right shunting PDAs, favela, pulmonic stenosis, subaiotic stenosis, ventricular septal defects and then there's obviously a handful that are a little bit more rare in comparison. And what are the ones that you'll be able to oscultate to detect, can you detect all of those that you mentioned? Yeah, pretty much. That's the nice thing in terms of congenital heart disease is most of them are going to produce fairly intense, loud heart members. They will have slightly different characteristics and again that can be really helpful based on oscultation because you can come up with a number of differentials that potentially lead to listening to a specific type of heart murmur. You know really I think off the top of my head you know one of the only ones that we sort of worry about not really creating any sound is a right to left shunting PDA. Again that's going to be rare in that instance and a lot of those dogs are going to present with clinical signs that are suggestive of a differential synosis. They may be exhibiting exercise intolerance sort of failure to thrive maybe not growing as much as their litter mates so there should be other kind of characteristic signs hopefully to pick up on if we can't actually hear a heart murmur but most of them should classically have something that we can listen to particularly if we do a thorough physical exam. And when you're listening so could you describe your thought process when you're listening to normal heart sounds like what what are you actually sort of listening for? I know we're going to maybe teach people some people how to suck experts always good to know how you're interpreting things. Yeah no it's definitely really good I think to just go back to basics and you know I think everybody will do this slightly differently but the first thing I always remind myself obviously when I'm listening to a heart is what are the normal heart sounds that I should hear and classically that's your love dub sound which is technically termed S1 and S2. S1 is going to be where your mitral antricuspid valve closes and that then enters the heart into our systolic component of the cardiac cycle and then that finishes off with S2 which is where your semi-luna valve so your aortic and pomonic valve close and that should be what is normal and so depending on where we place our stethoscope on the chest we can actually position it to hearing essentially the sort of area that indicates either the mitral tricuspid or the aortic and pomonic valves. And so is that like Pam on the yeah on the left hand side of the chest is that right yeah still the same? Yeah yeah exactly. And is it something that's obviously easier and big dogs or should you be able to actually listen to individual valves on your two hours? Yeah no it's a good question you know I think what I generally try to teach our students that come through and anyone really that asks that one sort of fresher is that I will tend to listen to at least four spots along the heart regardless of the size of the dog. Now bearing in mind that's obviously going to be trickier to try and isolate those different areas if you have a two kilo two hour and particularly if it's a puppy and so therefore it's smaller versus a dopamine or a great dane where they're going to have greater chest space. What I will say though is with our giant breed dogs actually trying to identify those exact locations can also be as equally tricky so the first thing that I'll always do to try and give me an indication of the first spot to listen to is I put both of my hands on either side of the chest I feel for where the prominent apex beat is and that's the region that I place my stethoscope on on the left side which indicates your apex which is your mitral valve area and then just as a general guidance to move up into the base on the left side which is where your aortic and pulmonic valves live it's going sort of a tricky thought process but your pulmonary artery and aorta both arise on the left side so you're going to hear murmurs correlate with those areas on the left side all you're doing is slipping your stethoscope essentially under the point of the triceps so within reason within kind of the scope of the dog breed that you have I try to still do that every time and when you were talking about sort of describing then murmurs how does how does one describe that and I suppose one of the things I've always sort of not always but thought about is like the intensity of that sound what does that equate to and is that a reliable thing for you or is it more of a interuse variability rather than in trade like is it good for you or is it actually useful information to remember? Yeah and again another like really interesting question because I do think this is an area even amongst cardiologists that there'll be some differences and that can be just potentially based on where you trained how you've adapted and listened to various different animals so if we're referring to intensity to me that's generally going to say well how loud is a heart murmur and if it's loud is it potentially incorporating your loved-dub sound so can you hear the loved-dub on either side and the murmurs kind of contained within those sounds so it's potentially not as loud or it's just so loud it's incorporating that area and I think that's where there can be a little bit of grey zone you know this is coming down to basics of saying well let's go ahead and grade a murmur our grading schemes are always going to be one through six and with five and six the murmurs where you can feel a palpable thrill between your fingers um ultimately what I try to put across to people is that whilst grading can be subjective probably the more important points when we're listening to heart murmurs is thinking about the location of where they're coming from again it gives an indication of the area within the heart that is affected and that you know again potentially gives you more information with regards to the disease and then also thinking about where exactly along our cardiac cycle is the murmur occurring is it systolic which is going to be in between your lub and dub so it's going to sound like a classic lub sh dub lub sh dub or if you have a diastolic it'll be lub dub sh lub dub sh and then obviously our kind of more obvious one which is our classic left to right shunting pda is our continuous so you hear it basically throughout the cardiac cycle so that's just a sh sh sh sounds a lot more like sort of the rolling sea coming in that's what I sort of think of that's very romantic I like that rolling sea rather than like continuous sounds a bit better and so you see when we're talking like with our puppy hat on again so so he's what what are the most common abnormal rhythms I know abnormal murmurs that you're going to hear and yeah would you mind sort of going through that with that period yeah so I think if we touch upon essentially the three most commented congenital disease processes we're going to see in young dogs so the first probably now overtaking the pda is actually going to be valvula pulmonic stenosis and again that's probably because of the breeds that we see that are just much more popular nowadays so our brachysophalic breeds are going to be predisposed to valvula pulmonic stenosis and that is going to sound like a classic left basilar so you're going higher up underneath the point of the elbow to listen for that portion it's the left side because the pulmonary artery arises on the left side and it is a systolic heart murmur with varying different grades for example we had one in today where the pressure gradient measured across that valve was severe but ironically actually that dog only ended up having a grade three out of six left basilar systolic murmurs so another little point of there is that murmurs grading does not necessarily correlate to the severity of that disease process so that would be classic for valvula pulmonic stenosis in terms of our next most common we're thinking about left to right shunting pda's so again we're wanting for our stethoscope to be on the left side we want it to be essentially in that basilar region or even really a little bit higher I used to sort of be taught that it was more of an auxiliary area that you're listening to so some people will refer to that as like the fifth area that you could listen for and I do think that's important because if you're not in the right spot for a left to right shunting pda there is a small chance that you're going to miss the diastolic components so you might not hear a complete continuous murmur and that in and itself is obviously tricky but to reassure some of our listeners you will still hear a loud systolic component and again obviously in that indication it's still going to be the suggestion to potentially refer on so those are going to be two of our most classics the last one which is interesting to chat about is subaortic stenosis so again in terms of breeds we're thinking of larger breed dogs here new fees are going to be a more commonly represented breed for that type of disease process and whilst subaortic stenosis will still also create a similar murmur to pomemonic stenosis so it's again it's a left basilar systolic heart murmur these cases can be interesting because if you feel their pulses at the same time you actually know that the pulses feel weak in comparison to what you would anticipate and they can almost be a little delayed and that's purely just because the heart is having to work against an obstruction on the left side so you have less time to get normal cardiac output out to the rest of the body and it takes longer so as a result your pulses can potentially be impacted so it's sort of not to forget that whilst listening to murmurs is really interesting your pulses can also give you potentially a little more information if we concentrate on that in our physical exams so the pomemonic stenosis and the sub pomemonic stenosis they sound very similar but it's mainly the breed differences that makes you think of one rather than the other? yeah no you could definitely think about breed differences there so like I said for valveular pomemonic stenosis you're going to have French bulldogs, English bulldogs, boxes, not limited to your brachycephalic so we will see it in animals like cocus manuals for example and obviously that's quite a common breed across the UK so we're going to see relatively higher numbers of that congenital disease process whereas aortic stenosis, sub aortic stenosis is going to me be a much more kind of classic disease process that affects our sort of larger or giant breed dogs so like I said new fees, golden retrievers, German Shepherd dogs those are going to be more of our kind of classic patients that are going to appear with that disease process but again not limited unfortunately you know particularly with levels of breeding that are happening there are chances for these congenital disease processes to occur in patients or breeds that we just don't 100% suspect it to happen in and as far as geographically do you think is there a difference or mainly as you said a difference in the popularity of a breed is that is that the main difference rather than different countries having different congenital problems? yeah so I've worked in the US now and I've worked in the UK geographically I would say we again most commonly would see valveular pulmonic stenosis and pDAs as our sort of most frequent disease processes and not uncommon for them to also potentially have both of those at the same time so I always like to call them two for one specials where they decide to have two congenital disease processes yeah geographically I do think it just is almost based on the area you are in sort of the popularity you know some of these breeds can be fairly expensive to buy now so it might be more common that we're seeing Frenchies for example across the Greater London area you know they're smaller breed dogs they're more compact they can live in flats and so the numbers that we're going to see are probably higher for those patients so it's sort of useful to think about from a general practitioner's perspective because you'll know kind of the more common breeds that you're seeing potentially in a certain area and maybe this is sort of a generalized way of thinking it but you know it might be that you see more labs more caucus particularly how in the countryside rather than sort of toy breeds or smaller breed dogs in the city but generally the numbers I would say are kind of equating to about the same across different continents and so if you identify like a murmur I don't know whether it's better to go in one individually and maybe we'll try and throw in some actual sort of heart sounds into this into this podcast as well but I suppose the questions that people are going to ask I suppose would be is it is it what I think it is I think maybe a lot of people might be not the continuous murmurs make the more sense to say that that's a problem and it's most likely a PDA I suppose what it's going to say is what are the options for that so you've you think you've got a PDA what should do and maybe the same for the other common ones yeah yeah so I mean you know those are all good questions because I think it's quite easy you know obviously to listen to a new puppy that's coming in that's having vaccinations the owner obviously may not have any idea that this is potentially a problem and that could potentially be quite a distressing thing to go through with a client and to have to let them know as well as taking on you know the sort of feeling that you're trying to grade work out where this murmur is coming from and what potential disease process that is so I think the kind of worthwhile thing to point out here is that if you are hearing a heart memo that you've now heard a couple of times based on a puppy coming back either for a physical or to complete its routine vaccinations is that it's never wrong to seek out a referral to a cardiologist in order to try and screen them to make sure that they potentially don't have something that one is either congenital disease or to rule out that it's not just a physiologic murmur and then based on that information echocardiography which is our sort of most commonly utilized non-invasive diagnostic that will give us the ability to determine structure and function of the heart we're able to make more logical decisions about what is potentially the next best approach and the good news is for a large number of these disease processes we can actually potentially do something about that and potentially give our animals a really good quality of life and a long life as well so if we think about a left to right shunting pda this is probably the one when people are the most familiar because what we have to offer really gives us excellent prognoses for these patients so they can either have an interventional procedure it's minimally invasive where we cut down to a femoral artery we basically place different catheters up through to the heart and we put a little device in that extra vascular vessel which is allowing the left to right shunting and we close that off so that option I think has about a 98% success rate that's associated with it so it's a really you know a really handy procedure and those patients can go home 24 hours after they can also have a surgical intervention where they can have a thoracotomy and you can basically go off and suture that vessel and close it down as well obviously a little more invasive in comparison to something that is a catheter based intervention but equally has quite high success results just based on the surgeon who's performing the procedure and so the the the one that up the femoral arteries at the same and plats and is that is that right is that the name of someone and they and the idea is that because you just you open up almost like an umbrella is that right and it and because the pressure on one side is greater than the pressure the other just closes it's quite quite elegant as opposed to elegant solution we like phase in fact don't we yeah yeah well we like something I think that we can that we can fix you know we can give an owner obviously you know the sad news that they have a congenital defect but the option that obviously this animal can go home have it fixed and basically live a life where they will end up dying not because of their congenital heart disease so yeah with PDAs we basically place this acdo you're exactly correct it looks like two little umbrellas that are stuck together and a portion of that will sit in the pulmonary artery and then the rest of it sits within the ductus itself and then it basically creates a little blood clot and over time that then becomes incorporated into the blood vessel it just endothelializes and then it lives with that dog forever and the as far as like if you solve that or or stop that from being a problem they go on and live a normal life as in there there's nothing directly related to that affecting them in a cardiac sense yeah yeah no exactly that yeah fixed exactly we actually we had a caucus manual in yesterday who was being referred for other reasons but had had a PDA occluded by us I think about 10 years ago and they'd perform some thoracic radiographs thought that the heart potentially looked a little big so because it had this history they just wanted to check to see how things were and it's not uncommon for them to have remodeling to their heart even post intervention that might not ever change but ultimately she looked great she'd had her PDA fixed and her heart was absolutely fine even with maybe a little bit of titch of heart enlargement and it's one other question PDA I know we haven't gone over the other couple first but is this congenital as in if a if say it was a female dog or male dog should they should they breathe do we know that information and they're more likely to have offspring that have that problem yeah no that's a really good point to bring up so these are congenital defects and they are inheritable so generally our advice anytime we see any congenital disease regardless of what it is is that that animal should not be bred because of the chances of passing down a congenital disease process either the same or different to what they have and then similarly we always advise that the parents from which that dog was bred from are not bred together and that they should be screened to make sure that we're not picking up on something potentially that is then obviously moving down a family line. Thank you so maybe we should get back to pulmonic stenosis though yeah so a valveula pulmonic stenosis also another condition that we can go in and do an interventional procedure for there is a lovely spectrum of valveula pulmonic stenosis lesions so this can be very dependent on what we see both echocardiographically and then depending on the breed we will additionally do things like CT in order to try and further characterize the lesion our lovely breakies of Alex also like to commonly get a coronary artery abnormality which is something that has to be definitively excluded via CT so for those cases they'll come in they'll have an echo if we're thinking about performing a balloon valveuloplasty particularly in breakies of Alex will also do a CT and then the procedure that we can do is something called a balloon valveuloplasty so similarly we basically enter through the jugular vein we place a series of wires and catheters allow for a balloon to lead up against that pulmonic valve and then essentially all we do is inflate it so it's a palliative procedure it's not something that is directly fixing the valve but what we can do is we can open up that valve in order to allow it to have more mobility and to decrease the obstruction that that right ventricle is having to fight against to get blood flow out into the lungs and again what we know is that depending on the dog as long as they're pulmonic valve annulus so that kind of width at which that pulmonic valve is sitting across as long as it's not narrow and hypoplastic we can get really good results from just doing a balloon valveuloplasty and again any clinical signs which maybe had been noted prior to this could potentially resolve we generally know we have about an 85% success rate at least dropping our pressure gradients by 50% or into the mild category and again those patients don't have to potentially suffer from exercise intolerance arrhythmiers right-sided heart failure so gives them a really good prognosis for the rest of their lives and you said that's palliations you're not fixing the problem but yeah how does it change their life expectancy compared to dogs that don't have that yes yeah so when we look at valveulopomonic stenosis we tend to grade them based on the severity of the obstruction that we measure and that's something we obtain through echo so they can be mild moderate and severe when we reach that moderate to severe category and particularly with our severely affected cases we know that those patients have a much higher risk of developing right-sided heart failure arrhythmiers and unfortunately sudden death so in those patients we always aim to try and perform a balloon valveuloplasty because it will then give them a really good prognosis following that procedure life spans prior to that probably are in the realm of about three to five years so we could end up actually doubling that life span for those patients and or they could go on to live in very normal life span for that breed okay and now they are the do you always place them on medications like sedenophyll or does it just depend on that pressure gradient? yeah so we more commonly use beta blockers whenever we're treating valveulopomonic stenosis again that can be dependent on the severity of their pressure gradient it can also be clinician dependent as well it's sort of not really been shown to create a huge survival benefit but it may help us with our procedures in terms of just decreasing the risk for arrhythmiers that can sometimes occur with us basically placing catheters and wires into the heart so a tenelol is the main one we use again usually we opt for that in patients that have moderate to severe disease mild patients typically don't need it so we had a little corgi cross with a French bulldog actually and that patient really only had trivial valveulopomonic stenosis so didn't go home with a tenelol we'll see him back in about a year's time see how things look but otherwise we'll probably never have to see him again that's good and then and then say finally say sub aortic stenosis say what are options for for these dogs yeah so sub aortic stenosis unfortunately is a disease process that we haven't really got amazing fixes for they have looked at previously not performed here at the RVCE but across the states basically performing a similar procedure to valveulopomonic stenosis so they'll perform a balloon valveular plastic and they can place what we call a cutting balloon in first to try and score the lesion sass or sub aortic stenosis is essentially created because of the presence of this little fibrous lesion or ridge that sits just underneath the aortic valve and so whilst any sort of fusion that could be created there might be ameliorated by the use of a balloon valveuloplasti again we can't ever really go in and fully ameliorate that lesion so it tends to be that our balloon valveuloplasti really doesn't come out with great results for reducing the level of obstruction so it's not recommended because we just are putting animals potentially through an expensive procedure that again doesn't give them you know longer in terms of their time frames what i will say with sass is that it also is very dependent on the gradient so whether it's a mild moderate severe and they've now actually classified a very severe category in this disease process so if dogs have a pressure gradient that's over 130 millimeters or between 80 to 130 millimeters then we know they potentially have a higher risk of dying suddenly and that's obviously the kind of most sad component that's associated with that disease but if they sit within the mild moderate or severe there are very limited chances that's actually going to happen so we end up medically managing these cases it's usually going to involve beta blockers for them and then any management for left-sided heart failure if they end up going into that but it can be quite variable as to which patient potentially develops that and equally they can still have a long period of time that they can be with us and see this is a problem not with the valve itself but just under that like a fibrous tissue and so is this something that say into the into the future with your your the possibilities of space there would it be something that could be surgically corrected if if you had like could open our surgery sort this out yeah no that's a good question actually I think theoretically it is something that could potentially be considered you know it is going to be largely advanced surgery they would require cardiopulmonary bypass if we were going into that area you know and I think the kind of the great question would be how much of that tissue do you then take away essentially with a scalpel plate so whilst it's a consideration I don't know that we're there yet and I think it would be sort of curious to see how those dogs potentially then recover from a procedure like that but like I said it might be the next option that is considered or tried just given that an interventional procedure at the moment is something that you know we don't usually tend to go towards so also a little tricky because you know they are performing things like trans catheter aortic valve replacements in humans if the aortic valve itself is directly impacted potentially if it's a large enough dog that is something that could be utilized in veterinary medicine I just don't know if we yet have devices that would help to sort of reduce that little phybrotic lesion that's sitting within the left and trickle our flow tract to give us the results that we would want. Is there anything comparable in people with that condition? Yeah so I believe in terms of people they're more commonly affected at the level of the aortic valve so you can have a valvular aortic stenosis the valve truly is affected or you can have sub aortic stenosis in humans what they'll typically do because they're more represented to have valvular aortic stenosis is they'll go in and they'll do a balloon valvular plastic across the aortic valve particularly when they're young kids that in and itself potentially reduces the function of that valve being able to close so they can develop aortic insufficiency and so usually what they'll do is they'll follow those kids through and when it's recommended they'll go in and actually replace those valves through a trans catheter aortic valve replacement procedure. Okay so getting back to it in the case is here if you if you're of that embacter's you diagnose a murmur that is still persistent say after a time of say second vaccination and then what should they do and this is when you can plug what you are doing at the moment or or no but in general what can what can we what can we do? Yeah yeah so I think you know the biggest thing is obviously education to the owners and advising them on being able to try and find out what the cause of the heart murmur is is it something that we have to potentially worry about is it something that we need to be able to routinely monitor and is it something that we're able to do something about can they actually have an interventional or a surgical procedure that could fix an underlying congenital disease process if it is noted so to me really the best thing is to refer a patient on to a cardiologist or to a set holder here in the UK in order to try and find out more information about what's going on with that heart. Like I said for most people it will mean that they are performing an echocardiogram which is fortunately a very quick non-invasive and non-harmful test to the patient. If they're a wriggly puppy they might need a little sedation obviously to just keep them still for 20 minutes but otherwise that provides us with the most amount of information. And you know what I would say is that most cardiologists most holders are really happy to talk about these cases if you have one and you want to talk through an ocultation or what you should do so you know definitely bring us up. The obviously at the moment has a puppy clinic so we are seeing puppies specifically on Wednesdays for this exact reason it's a service that is just dedicated to making sure we're screening puppies for congenital heart disease so you know by all means definitely get in touch you know we'd rather obviously try to be helpful in this scenario and give you information that may help an owner to make a decision process. So what is the earliest time that you think it's appropriate to say if you hear a murmur in a puppy that you think it will merit a scam and I suppose conversely if people wait I imagine that as you mentioned there's cardiac remodeling that maybe you know to know what it is is a good idea sooner rather than later but I suppose how soon is too soon? Yeah so I would generally say that probably there's sort of no time frame which is too soon it probably depends a little bit on the client and how worried they might be if you're relaying the news that they have a heart lemma. Equally I also think that there are always screening tests that you can do in general practice so thoracic radiographs can be really helpful potentially of giving an overall indication of heart size is there potentially an area so sometimes your pulmonary artery can look enlarged on your thoracic radiographs and again that may give you more of an indication of how quickly to refer on. It also probably depends a little bit on the intensity or how loud the heart murmur is so if you're hearing a really loud heart murmur let's say it's a grade four or you're feeling a thrill so a grade five or a six heart murmur. Those are cases where again I would say that there's generally no hesitation to referring particularly even if it's a 12 week old coming in for its first set of vaccinations. If it's a quieter murmur you could always consider obviously waiting a time frame to see if that's something that potentially resolves by itself and if it does it's probably saying well hey this is more likely a physiologic heart murmur and if the puppy comes back within a month or two and it's still there then you have more reason to say well hey let's get this checked out and referred on. You are right though obviously these disease processes do have consequences and if we're sort of left with a longer period of time there may be more significant remodeling associated with their heart so actually referring earlier on may give us answers sooner and we may be able to do interventions faster before we see some of these more negative consequences arise. Am I right in thinking in the case as well that there's a part from like there is no other alternative really apart from echocardiography for this maybe voltage-cated CT but that's not going to be necessarily accessible but there's no you know it doesn't look at looking at troponins or whatever else is not going to help right like they need an echocard. Yeah yeah unfortunately from a biomarker perspective they're not sensitive and specific enough specifically for congenital heart disease to tell us one type of disease process or not. You know I do think it will be interesting to see how things progress over the next 10 years with things like artificial intelligence. So you know I know that there are ongoing stethoscope studies potentially that may help with osculation and helping with leading to a specific differential or diagnosis just based on an osculation and maybe we'll have better information in a few years time for that. ECGs sometimes are things to think about so depending on the cures complex amplitude and voltage some people will say obviously if you've got taller cures complex is potentially that indicates towards left ventricular dilation and again that might help but it doesn't 100% tell you what type of congenital disease process is going on so really the best test to give us the most information is going to be echo and that's probably striking the better balance with regards to finances and giving you answers. And also there's not non-invasive as well which would be which is ideal as that so a good way to test things. Maybe is there anything else you think we'd like to cover with this? Yeah I mean I think you know the last thing to obviously to just sort of write home about is that you know we do see a range of congenital processes that we've not discussed today. So things like VSD's, tetrology or phalloe. We've been seeing larger numbers of what we call arteriovenous malformation so rather than a congenital disease process directly impacting the structure of the heart we can have these abnormal vessels connecting the systemic to the venous circulatory systems within the abdomen and as a result that actually can act like a pda and create volume overload of the heart and that has been noted in patients under the age of one to cause left-sided congestive heart failure so you know I think that sort of just having that awareness that there can be some quite weird and wacky things out there and if there are ever any question marks if you are worried with regards to cardiac disease, congenital heart disease you know it's always worth asking the question. Emailing your local cardiologist you know we do a fair amount of free advice through our email and hopefully we can again give you some information and also sort of trust the tools that you have don't be afraid to obviously place things like ECGs and thoracic radiogross in order to try and give you maybe a little bit more information to help. Cool well thank you for that maybe um what we could do is if I could ask you to mimic those three murmurs again and then we'll insert some heart sounds for people to listen to with you um top and telling that would that be would that be okay so if I ask you to mimic a pda yeah so pda is our continuous heart murmurs so this is the one that sounds like the C to me so it's a shh shh shh shh shh shh shh shh sound the next one probably is the systolic murmurs so that's going to refer obviously to different locations that can be apical or basilar if we're talking about our classic ones here today so your vavulariotic stenosis or your pomonex stenosis um so that's just a sharp shh shh shh shh and that's incorporated within your love dub sounds the kind of more uncommon ones that we hear with congenital disease are what we call two-throw murmurs or diastolic murmurs so diastolic obviously different component of your cardiac cycle so you would hear your love dub and then the murmurs so shh love dub shh love dub shh for any of our practitioners that practice both equine medicine and um small animals you're more likely to hear diastolic murmurs in horses because they will develop degenerative aortic valve disease so they get leaky aortic valves and they have diastolic murmurs which can be really nice to listen to and then two-throw murmurs these are really fun murmurs it's usually if you've got a combination of different defects so for example if we had vavular pomonex stenosis so we've still got that pressure gradient that obstruction the right ventricles having to press up against um as well as a leaky pomonex valve so insufficiency you can have a murmur which literally switches between systole and diastole so it's a shh shh shh shh shh shh shh sound um again very rare but they are out there and it's sort of fun to listen to well thank you so much Nick as for your time and maybe we should wrap it up there but uh don't be strange you can come back and talk about something something else that would be great um so um yeah thank you so much your time so we'll wrap it up there um and thanks again for listening so don't forget to hit that subscribe button on your generic fruit race device and that way you don't have enough to worry about missing a podcast if you leave a five star review on Apple podcast Spotify wherever you get your podcast that would be great tell some friends vet friends anyone um that would be good and we'll play some shownates on the obviously pages so if you just type in rvc clinical podcast need your search engine of choice that should be top of the tree if you have any comments or suggestions for this podcast please get in touch you can either email debuffure.avc.ac.uk or podcast.avc.ac.uk or follow us on Instagram @avc clinical podcast until next time bye bye