Echocardiography

Virginia B. Reef, DVM, Diplomate ACVIM (LAIM), Mark Whittier and Lila Griswold Allam
Professor of Medicine, Director of Large Animal Cardiology and Ultrasound

Echocardiography is the pivotal diagnostic modality for assessing the clinical significance
of a heart murmur in horses. The echocardiographic examination can be used to identify the
etiology of a heart murmur, determine the severity of the underlying disease that is present,
and assess its potential impact on the horse’s performance and life expectancy. The
echocardiographic examination is also the cornerstone of the diagnosis of endocarditis,
pericarditis, and myocardial dysfunction in horses. An echocardiographic examination is
indicated in horses with loud systolic murmurs, holodiastolic murmurs, continuous mur-
murs, muffled heart sounds, pericardial friction rubs, and in horses with exercise intoler-
ance or poor performance.
Clin Tech Equine Pract 3:274-283 © 2004 Elsevier Inc. All rights reserved.

KEYWORDS echocardiography, murmurs, valvular regurgitation, congenital heart disease,

pericarditis, endocarditis

E chocardiography is an indispensable part of the cardio-

vascular examination in horses presenting with mur-
murs, arrhythmias, or for a complete poor performance eval-
uation. The echocardiographic examination allows the
veterinarian to accurately identify the cause of a heart mur-
mur and assess its hemodynamic impact.1–5 This information
can then be used to determine the effect the abnormality may
have on the horse’s current and future performance ability
and to determine whether this abnormality is likely to affect
the horse’s life expectancy.1,2 The echocardiographic exami-
nation also is an important part of a prepurchase or insurance
examination when a cardiovascular abnormality is detected.
Real-time two-dimensional, M-mode, and color flow Dopp-
ler echocardiography are part of the routine echocardio-
graphic examination, with pulsed wave and continuous wave
Doppler echocardiography used when indicated by the echo-
cardiographic findings.
The echocardiographic examination with simultaneous
electrocardiography is performed from the right and left
parasternal windows. A low frequency transducer (2.5 MHz)
is positioned in the right fourth intercostal space midway
between the point of the shoulder and the point of the elbow.
The transducer is directed cranially to image the right ven-
tricular outflow tract, directly across the chest to image the
left ventricular outflow tract, and caudally to image the four
cardiac chambers. The long axis view is obtained with the
beam tilted slightly cranially or clockwise to the 1 o’clock
position, while the short axis views are obtained with the
New Bolton Center, University of Pennsylvania, Kennett Square, PA.
Address reprint requests and correspondence to: Virginia B. Reef, DVM,
University of Pennsylvania, New Bolton Center, 382 West Street Road,
Kennett Square, PA 19348. E-mail: vreef@vet.upenn.edu
transducer rotated clockwise to the 4 o’clock position. In the
short axis view, the transducer is angled caudally to image the
mitral valve, slightly ventral to image the left ventricle, and
dorsal and slightly cranial to obtain the aortic valve. A small
clockwise rotation is usually necessary to obtain a complete
short axis image of the aorta at the valve. The M-mode echo-
cardiograms are performed by bisecting these structures with
the M-mode cursor, yielding left ventricular, mitral valve,
and aortic valve M-mode echocardiograms. The right and left
ventricular M-mode measurements should be obtained just
below the mitral valve. Right ventricular internal diameter,
interventricular septal thickness, left ventricular internal di-
ameter, and left ventricular free wall thickness are measured
at end diastole and end systole. The mitral valve M-mode
should be obtained through the center of the septal leaflet of
the mitral valve with the free wall leaflet visible as a smaller
mirror image. The distance between the maximal opening of
the mitral valve or E point and the interventricular septum at
its peak downward deflection (SEP or EPSS) should be mea-
sured. The aortic root M-mode should be obtained through
the center of the aortic root. Measurements of the left atrial
appendage are made in systole, while the aortic root diameter
is measured in diastole. The time from the opening to the
closure of the aortic valve (ET or ejection time) should also be
measured. Color flow, pulsed wave, and continuous wave
Doppler echocardiography are performed using the two-di-
mensional images to guide the Doppler placement.6,7 In all
horses with a loud left-sided systolic murmur, a holodiastolic
murmur, or atrial fibrillation, an echocardiographic exami-
nation should also be performed from the left cardiac win-
dow.1,6 Examination of the mitral valve, left atrium, and left
ventricle in the long axis plane is performed in the left fifth
intercostal space with the transducer rotated slightly cranially

274 1534-7516/04/$-see front matter © 2004 Elsevier Inc. All rights reserved.
doi:10.1053/j.ctep.2005.03.013
Echocardiography 275

Table 1 Echocardiographic Measurements in Normal Horses

Measurement (cm)
TB* TB** FTB/WB† Std‡ Qtr type§
Mean SD Mean SD Mean SD Mean SD Mean SD
LVIDd¶ 11.90 0.71 11.92 0.76 11.06 1.34 10.7 0.3 9.3 0.3
LVIDs 7.35 0.72 7.45 0.61 6.11 0.9 7.0 0.6 5.7 0.23
FS 38.76 4.59 37.42 3.86 44.1 6.4 34.7 4.1 38.6 1.6
LVd 2.39 0.26 2.32 0.38 2.92 0.49 2.7 0.2
LVs 3.96 0.93 3.85 0.41 4.45 0.59 3.9 0.4
IVSd 3.02 0.39 2.85 0.28 3.06 0.6 3.0 0.2
IVSs 4.55 0.55 4.21 0.46 4.81 0.7 4.7 0.3
ARd 8.5 0.51 7.95 0.53 7.31 0.83 7.7 0.16
*Data obtained from 26 Thoroughbred horses with a mean weight of 517 kg. (From: Long KJ, Bonagura JD, Darke PG: Standardized imaging
techniques for guided M-mode and Doppler echocardiography in the horse. Equine Vet J 24:226 –235, 1992.)
**Data obtained from 37 Thoroughbred horses with a mean weight of 517 kg. (From: Patteson MW, Gibbs C, Wotton PR, et al: Echocardio-
graphic measurements of cardiac dimensions and indices of cardiac function in normal adult Thoroughbred horses. Equine Vet J Suppl
19:18 –27, 1995.)
†Data obtained from 100 horses (English Thoroughbreds and French riding horses) with a mean weight of 445 kg. (From: Lescure L, Tamzali
Y: Valeurs de reference en echocardiographie TM chez le cheval de sport. Rev Med Vet 135:405– 418, 1984.)
‡Data obtained from 25 normal horses weighing approximately 300 kg. All values reported as ⴙ/ⴚ SEM. (From: Pipers FS, Hamlin RL:
Echocardiography in the horse. J Am Vet Med Assoc 170:815– 819, 1977.)
§Data obtained from 23 Standardbred horses with a mean weight of 427 kg. (From: Bakos Z, Voros K, Jarvinen T, et al: Acta Vet Hungarica
50:273–282, 2002.)
¶Abbreviations: LVIDd, left ventricular internal diameter at end diastole; LVIDs, left ventricular internal diameter at end systole; FS, fractional
shortening; LVd, left ventricular free wall thickness at end diastole; LVs, left ventricular free wall thickness at end systole; IVSd,
interventricular septal thickness at end diastole; IVSs, interventricular septal thickness at end systole; AR, aortic root diameter at end
diastole; LAD, left atrial diameter in systole; RVd, right ventricular internal diameter at end diastole; RVs, right ventricular internal diameter
at end systole.

or counterclockwise to the 11 o’clock position. A short axis
view of the mitral valve should be performed in all horses
with suspected mitral valve disease by rotating the transducer
cranially 90° or counterclockwise to the 8 o’clock position.
The left ventricular outflow tract is imaged by angling the
transducer more cranially or by moving forward into the left
fourth intercostal space. The pulmonic valve is imaged in the
third intercostal space using the same transducer angulation.
Relative assessments of cardiac size should be followed by
objective M-mode and two-dimensional echocardiographic
measurements. The normal horse’s heart should fit easily on
a displayed depth of 28 cm. Both atria should appear similar
in size when imaged in the four-chamber view. The right
ventricle should be approximately one-quarter to one-third
of the diameter of the left ventricle in this view. The geometry
of the right ventricle makes assessing right ventricular size
difficult. The normal cardiac dimensions vary significantly
between breeds of horses and thus it is important to have
some idea what is normal for each breed when assessing an
individual animal with cardiovascular disease (Table 1). In
general, Quarter Horses, Morgans, and Arabians have smaller
cardiac dimensions than Standardbred horses, with Warm-
bloods and Thoroughbreds having the largest normal cardiac
dimensions of the light horse breeds. These echocardio-
graphic dimensions parallel the heart size to body weight
information for the different breeds. Draft horses have the
smallest heart size to body weight ratio. Therefore, many
draft horses have echocardiographic dimensions similar to
those found in Thoroughbred or Warmblood horses. Larger
but normal echocardiographic measurements have been
found in the large Percheron horses used for pulling the
eight-horse hitches.
One of the most common cardiovascular problems faced
by the equine practitioner is determining the significance of a
murmur or other abnormal heart sounds detected associated
with the cardiac cycle.1–5 The prevalence of functional sys-
tolic murmurs in horses was 57.7% in one recent study.4 The
characteristics of the murmur identified can help determine
the probable cause of the murmur, but the echocardio-
graphic examination is necessary to accurately identify the
etiology of the murmur and characterize the severity of the
underlying cardiac abnormality.1,2 Clinically silent regurgita-
tion has been detected using color flow Doppler echocardi-
ography at all the equine heart valves.7,8
Indications for an
Echocardiogram in Horses with
a Right-Sided Systolic Murmur
An echocardiographic examination is indicated in horses
with a right-sided systolic murmur when the murmur is
grade 4 to 6/6 and holosystolic or pansystolic, when there is
also a murmur of pulmonic stenosis or mitral regurgitation,
when the horse is in atrial fibrillation, when there are clinical
signs of poor performance, or when the horse has concurrent
respiratory signs consistent with lower airway disease. The
two main differentials for a loud right-sided systolic murmur
are tricuspid regurgitation and a ventricular septal defect
(VSD).
Tricuspid Regurgitation
The murmur of tricuspid regurgitation is a band-shaped ho-
losystolic or pansystolic murmur with its point of maximal
intensity in the right third to fourth intercostal space. There is
276
Figure 1 Color flow Doppler echocardiogram of the jet of tricuspid
regurgitation obtained from a horse with mild tricuspid regurgita-
tion. The arrow points to the greenish jet of tricuspid regurgitation
in the right atrium (RA) during systole. RV, right ventricle; LV, left
ventricle; AR, aortic root. This echocardiogram was obtained from
the right parasternal window.
a relationship between the intensity of the tricuspid regurgi-
tation murmur and the jet of tricuspid regurgitation detected
with color flow Doppler echocardiography (Fig. 1).9 Horses
with louder murmurs have significantly larger and longer jets
than horses with low-grade murmurs.9 Tricuspid regurgita-
tion is common in Standardbred and Thoroughbred race-
horses and in National Hunt horses (horses that race over
fences in the UK).1,2,4,5,8 The prevalence of tricuspid regurgi-
tation was 16.4% in the National Hunt horses,5 compared
with 28% in racing Thoroughbreds.4 The prevalence of tri-
cuspid regurgitation in Thoroughbred racehorses before
training was 12.7% and increased to 25.5% after training.3
Small amounts of tricuspid regurgitation are detected in
many horses with normal right-sided cardiac dimensions.
Larger amounts of tricuspid regurgitation result in right atrial
and right ventricular enlargement.2,10 Paradoxical septal mo-
tion is detected echocardiographically when right ventricular
volume overload is present (Fig. 2). Abnormalities of the
Figure 2 M-mode echocardiogram of a horse with paradoxical septal
motion secondary to severe tricuspid regurgitation. Notice the
movement of the interventricular septum (arrow) toward the right
ventricle (RV) in systole rather than toward the left ventricle (LV).
This echocardiogram was obtained from the right parasternal
window.
V.B. Reef
Figure 3 Spectral tracing of the tricuspid regurgitation jet (arrow)
obtained with continuous wave Doppler echocardiography from a
horse with atrial fibrillation, mitral and tricuspid regurgitation. The
peak velocity of the jet varies up to 4 m/sec indicating elevated
pulmonary arterial pressures. This echocardiogram was obtained
from the right parasternal window.
tricuspid valve leaflets are infrequently detected in horses
with tricuspid regurgitation. The detection of irregular hypo-
echoic to echoic vegetative masses on the valve leaflets or
chordal structures is consistent with bacterial endocarditis.
Tricuspid valve endocarditis has been most commonly de-
tected in horses with septic jugular vein thrombophlebi-
tis.1,2,11,12 The prognosis for a horse with tricuspid valve en-
docarditis is more favorable than for left-sided endocarditis,
if a bacteriological cure can be obtained.1,2,12 Color flow or
pulsed wave Doppler echocardiography usually reveals a jet
directed toward the aortic root that is best imaged in the left
ventricular outflow tract view.1 The velocity of the tricuspid
regurgitation jet detected with continuous wave Doppler
echocardiography can be used to estimate pulmonary arterial
pressure in horses with no evidence of right ventricular out-
flow tract obstruction. Using the Bernoulli equation (4v2) the
right ventricular and pulmonary artery pressure can be esti-
mated by adding the estimated right atrial pressure to the
Doppler-derived pressure difference between the right
atrium and ventricle (Fig. 3). The estimated right atrial pres-
sure is 15 mm Hg in horses with mild tricuspid regurgitation
and 20 mm Hg in horses with moderate to severe tricuspid
regurgitation. A jet velocity of ⬍2.5 m/sec is consistent with
normal to near normal pulmonary arterial pressures.
Tricuspid regurgitation is a common clinically insignifi-
cant valvular insufficiency in young race horses and rarely
affects performance, unless the regurgitation is severe.2–5
Most horses with tricuspid regurgitation also have normal life
expectancies. Tricuspid regurgitation is commonly detected
concurrently in horses with moderate to severe mitral regur-
gitation and is present in most horses with left-side conges-
tive heart failure.1,2
VSD
VSDs are the other common cause of loud right-sided systolic
murmurs and can be differentiated from tricuspid regurgita-
tion murmurs by the detection of a relative pulmonic stenosis
murmur in the left third intercostal space.1,2,13–15 The most
Echocardiography
Figure 4 Two-dimensional echocardiogram of a ventricular septal
defect obtained from the right parasternal window of a horse with a
3.0-cm defect. Notice the defect (arrow) in the membranous portion
of the interventricular septum underneath the septal leaflet of the
tricuspid valve. RA, right atrium; RV, right ventricle; LV, left ventri-
cle; AR, aortic root.
common location of the ventricular septal defect in the horse
is in the inlet portion of the interventricular septum.1,2,13,15,16
In these horses, the band-shaped pansystolic murmur with
its point of maximal intensity in the right third to fourth
intercostal space (VSD murmur) is louder than the holosys-
tolic crescendo decrescendo murmur of relative pulmonic
stenosis that is loudest in the left third intercostal space.1,2,15
Echocardiographically the membranous VSD is imaged un-
derneath the septal leaflet of the tricuspid valve and the right
coronary or noncoronary cusp of the aortic valve and thus is
best imaged in the left ventricular outflow tract view (Fig.
4).1,2,15,16 With M-mode echocardiographic examination
scanning from the left ventricle to the aortic root, drop-out of
the basilar portion of the interventricular septum and/or aor-
tic root echo in systole is found with larger ventricular septal
defects.1,14,16 Pulmonary artery dilation can occur associated
with increased flow out the pulmonary artery.1,15,16 The ma-
jority of ventricular septal defects in horses are small, mea-
suring 2.5 cm or smaller in two mutually perpendicular
planes.1,15 In ponies and small horses, the ratio between the
VSD and the aortic root can be used to help determine the
hemodynamic significance of the VSD.17 If the diameter of
the VSD is less than one-third of the diameter of the aortic
root, the VSD is relatively restrictive. Color flow Doppler or
contrast echocardiography demonstrates the typical left to
right shunt.1,2,13,15,16 The hemodynamic effect of the VSD can
be estimated by measuring the peak velocity of the shunt with
continuous wave Doppler echocardiography (Fig. 5).1,2,15,16
The Doppler interrogation should be made as parallel as pos-
sible to the shunt to obtain an accurate shunt velocity. The
hemodynamic significance of the VSD can be estimated by
using the Bernoulli equation (4v2) where v is the shunt ve-
locity obtained with CW Doppler. Subtracting this value
from the systolic blood pressure obtained from the horse
yields an estimate of right ventricular pressure. A high-veloc-
ity jet is indicative of a large pressure difference between the
left and right ventricles and a restrictive VSD. A low-velocity
jet is associated with a severe left ventricular volume overload
and a VSD that is hemodynamically significant. Left atrial and
277
left ventricular enlargement are commonly detected in horses
with a ventricular septal defect.1,2,15,16 Aortic valve prolapse
and aortic regurgitation can occur in horses with ventricular
septal defects.1,2,15,16,18 Mitral regurgitation often develops in
horses with moderate to large ventricular septal defects.1,15
Horses with VSDs that are 2.5 cm or smaller and with a
shunt velocity of 4 m/sec or greater usually have an excellent
prognosis for life and performance.1,2,15,16 These horses
should also have only mild left atrial and left ventricular
enlargement, normal myocardial function, little or no aortic
regurgitation, and little or no mitral regurgitation detected
echocardiographically. Horses with VSDs that are less than
2.5 cm but greater than 3.5 cm usually have a shunt velocity
of 3 to 4 m/sec and a normal life expectancy, although are
usually only successful in lower levels of athletic work. The
horses with VSD shunt velocities less than 3 m/sec and VSDs
that are greater than 3.5 cm in diameter must be given a
guarded to grave prognosis for performance and life. These
horses usually have marked left atrial and left ventricular
enlargement and volume overload. A large amount of con-
current aortic or mitral regurgitation also decreases the prog-
nosis in these horses, as does the presence of significant left
ventricular dysfunction.1,2,15 The development of aortic re-
gurgitation usually occurs due to loss of support of the aortic
root and is most likely in horses with malalignment VSDs.
The mitral regurgitation usually develops as the left ventric-
ular volume overload becomes more severe and the mitral
annulus dilates. The presence of a large VSD in the muscular
portion of the interventricular septum or multiple VSDs also
decreases the prognosis for the affected horse.
Outflow VSD,
Tetralogy of Fallot,
VSD and Pulmonic Stenosis
If the systolic murmur in the left third intercostal space is
louder than the systolic murmur in the right third to fourth
intercostal space, a VSD in the outflow portion of the inter-
ventricular septum, Tetralogy of Fallot, or a VSD plus pul-
Figure 5 Spectral tracing of the jet associated with a ventricular
septal defect obtained from a horse with continuous wave Doppler
echocardiography. The echocardiogram was obtained from the
right parasternal window demonstrating the left to right shunt (the
blood flow is toward the transducer). The shunt velocity is high (4.8
m/sec), indicating a restrictive ventricular septal defect.
278
Figure 6 Two-dimensional echocardiogram of the caudal accessory
leaflet of the mitral valve prolapsing into the left atrium (LA) in a
horse with mitral valve prolapse. Notice the bulging of the caudal
accessory leaflet into the left atrium (arrow). This echocardiogram
was obtained from the left parasternal window. LV, left ventricle.
monic stenosis must be considered in the differential diagno-
sis.1 A careful echocardiographic examination will enable the
echocardiographer to differentiate these conditions. With a
VSD in the outflow portion of the interventricular septum
(the most likely diagnosis), the defect is more difficult to
image and is usually best imaged in the short axis view im-
aging just beneath the aortic valve. The combination of a VSD
and pulmonic stenosis has been infrequently reported and
has occurred with both membranous and perimembranous
locations of the VSD.1 Both a hypoplastic pulmonary artery
and a bicuspid valve have been reported in foals with a VSD
and pulmonic stenosis. With Tetralogy of Fallot, there is
usually a large perimembranous ventricular septal defect
with an overriding aorta, right ventricular outflow tract ob-
struction, and secondary right ventricular hypertrophy.1,16 In
most horses, the right ventricular outflow tract obstruction
consists of a hypoplastic pulmonary artery, rather than true
valvular pulmonic stenosis. A contrast echocardiogram will
demonstrate the echo contrast entering the right atrium, go-
ing to the right ventricle, and then simultaneously appearing
in the pulmonary artery and aorta.1,16 The prognosis for a
horse with an outflow tract VSD is similar to that for a horse
with an inflow tract VSD of similar size. The addition of
pulmonic stenosis to the VSD worsens the prognosis. Both
the severity of the pulmonic stenosis and the size and the
location of the VSD affect the prognosis for a horse with a
VSD and pulmonic stenosis. The prognosis for a horse with
Tetralogy of Fallot is grave, and most of these horses are
humanely destroyed before they are 5 years of age.1 Two
cases of cyanotic Tetralogy of Fallot have been seen by the
author that lived to be 7 and 8 years of age, respectively. The
older horse developed left-sided congestive heart failure and
had to be humanely destroyed.
Indications for an
Echocardiogram in Horses with
a Left-Sided Systolic Murmur
Horses with left-sided holosystolic or pansystolic murmurs
that are a grade 3/6 to 6/6 with the point of maximal intensity
V.B. Reef
in the mitral to aortic valve area should be considered to have
mitral regurgitation until proven otherwise. An echocardio-
gram is indicated in these horses. Other indications for an
echocardiogram in horses with a left-sided systolic murmur
are when the horse is in atrial fibrillation, when the horse has
clinical signs of cardiovascular disease, and when the horse
has clinical signs of lower airway disease or poor perfor-
mance. The echocardiogram should be performed from both
the right and left sides of the thorax in all horses with signif-
icant left-sided systolic murmurs.
Mitral Regurgitation
Mitral regurgitation murmurs were detected in only 5.6% of
National Hunt horses5 and in 7.3% of Thoroughbred race-
horses before training, while it was detected in 21.8% of
Thoroughbred racehorses after training.3 Murmurs of mitral
regurgitation are usually loudest in the mitral to aortic valve
area and radiate dorsally, dorsocranially, or dorsocaudally,
depending on the direction of the regurgitant jet.1,19 Most
murmurs of mitral regurgitation are a grade 3 to 6/6, but
softer murmurs may be detected, particularly in horses with
atrial fibrillation. While most murmurs of mitral regurgita-
tion are holosystolic or pansystolic, murmurs of mitral valve
prolapse are usually mid- to late systolic and usually have a
crescendo quality.2 Murmurs associated with a mitral rup-
tured chordae tendineae are usually pansystolic and honk-
ing, while murmurs associated with degenerative valve dis-
ease are more likely to be band-shaped and either
holosystolic or pansystolic. Musical systolic murmurs are
consistent with some portion of the mitral valve apparatus
vibrating in the mitral regurgitation jet, such as a ruptured
chordae tendineae or, less commonly, a flail portion of the
mitral valve leaflet. Careful echocardiographic examination
of the mitral valve leaflets from both the right and left sides of
the thorax usually reveals abnormalities of the leaflets. With
mitral valve prolapse, a portion of the valve leaflet is imaged
bulging backwards into the left atrium during systole (Fig.
6).1,19 With a ruptured chordae tendineae, an echoic mobile
structure is imaged everting or flipping into the left atrium,
Figure 7 Two-dimensional echocardiogram of a ruptured chordae
tendineae from the septal leaflet of the mitral valve. Notice the
echoic linear chordal structure everting into the left atrium (LA) in
systole (arrow). This echocardiogram was obtained from the right
parasternal window. LV, left ventricle; RV, right ventricle.
Echocardiography
Figure 8 Two-dimensional echocardiogram obtained from a horse
with bacterial endocarditis affecting the mitral valve. Notice the
echoic round thickening on the free edge of the septal leaflet of the
mitral valve (arrow) consistent with healing. This echocardiogram
was obtained from the right parasternal window. RA, right atrium;
RV, right ventricle; LA, left atrium; LV, left ventricle.
usually during systole (Fig. 7).1,19 If the mitral valve leaflet is
flail, the affected leaflet is imaged moving independently
from the rest of the mitral valve in systole or diastole.1,19 The
mitral valve leaflets may be thickened, a common finding in
horses with band-shaped holosystolic or pansystolic mur-
murs. If the mitral valve leaflet is thickened and hypoechoic,
a valvulitis may be present. If the valve appears thickened and
echoic, degenerative changes and fibrosis are more likely.
Although bacterial endocarditis is relatively uncommon in
horses, the mitral valve is a common site for bacterial endo-
carditis in horses, when it occurs.1,12,19,20 The vegetative en-
docarditis lesions initially appear as irregular, proliferative,
hypoechoic clumps that are usually located on the valve leaf-
lets or, less frequently, involve the chordae tendineae. As the
lesions become more chronic and respond to antimicrobial
treatment, the masses become smaller, smoother, and more
echoic (Fig. 8).1,12 With mitral regurgitation, the left atrium
and left ventricle enlarge and a pattern of left ventricular
volume overload is detected.1,2,19 As the mitral regurgitation
becomes more severe, the interatrial septum may be imaged
bulging rightward and dilation of the pulmonary veins is
detected. Enlargement of the pulmonary artery relative to the
diameter of the aortic root in horses with mitral regurgitation
is indicative of pulmonary hypertension and left-sided heart
failure.1,2,19 A diameter of the pulmonary artery measured
from the right parasternal window that exceeds the similarly
measured aortic root diameter by 1 cm is indicative of sys-
temic pressures in the pulmonary artery. These horses are not
safe to ride because they are at risk for pulmonary artery
rupture and sudden death.1,2,19
Accurately depicting the size of the jet of mitral regurgita-
tion is difficult in horses because the jets of mitral regurgita-
tion are often perpendicular or nearly so to the ultrasound
beam. The actual velocity of the mitral regurgitation jet is
usually underestimated due to the large angle between the
ultrasound beam and the jet. If a continuous wave Doppler
tracing of the mitral regurgitation can be obtained, it can be
used to estimate the severity of the mitral regurgitation. The
detection of a high-velocity jet of mitral regurgitation indi-
279
cates that there is a large pressure difference between the left
atrium and left ventricle and mild mitral regurgitation.
Horses with mitral valve prolapse usually have a long narrow
jet of mitral regurgitation, mild mitral regurgitation, and mild
left atrial and left ventricular enlargement (Fig. 9). These
horses have an excellent prognosis for life and perfor-
mance.1,2 The mitral regurgitation in horses with mitral valve
prolapse usually progresses slowly, if at all. Horses with mi-
tral valve thickening associated with degenerative changes
usually have a slow progression of their valvular heart dis-
ease. These horses may have a shortened performance life
and life expectancy, but the deterioration of their cardiovas-
cular status usually happens over years.1,2 Occasionally,
however, horses with diffuse echoic thickening of the mitral
valve have a more acute or subacute course and progress
rapidly to congestive heart failure. Horses with a ruptured
mitral valve chordae tendineae or flail mitral valve leaflet
usually have an acute onset of moderate to severe mitral
regurgitation and must be given a guarded to grave prognosis
for performance and life.1,2 These horses usually have a lower
velocity of their mitral regurgitation jets due to the significant
increase in left atrial pressure present with moderate to severe
mitral regurgitation. Similarly, a horse with mitral valve en-
docarditis must also be given a guarded to grave prognosis for
life.1,2,12 Achieving a bacteriological cure in horses with mi-
tral valve endocarditis is difficult. Once the bacteriological
cure is achieved, significant scarring of the valve often occurs,
leading to rapid progression of the mitral regurgitation and a
shortened performance life and life expectancy.1,2,12
Indications for an
Echocardiogram in Horses
with a Holodiastolic Murmur
An echocardiogram is indicated in horses with a holodiastolic
murmur when the arterial pulses are bounding, when there is
Figure 9 Color flow Doppler echocardiogram of the jet of mitral
regurgitation obtained from a horse with mitral valve prolapse and
mild mitral regurgitation. Notice the small narrow green jet in the
left atrium (LA) during systole (arrow). This echocardiogram was
obtained from the left parasternal window. LV, left ventricle; MV,
mitral valve.
280
Figure 10 Two-dimensional echocardiogram of a horse with degen-
erative aortic valve disease and mild aortic regurgitation. Notice the
echoic thickening parallel to the free edge of the left coronary cusp
of the aortic valve (arrow). This echocardiogram was obtained from
the right parasternal window. RA, right atrium; LV, left ventricle;
AR, aortic root.
a concurrent murmur of mitral regurgitation, when the horse
is in atrial fibrillation or is having ventricular premature
beats, or when the horse is exhibiting clinical signs of cardio-
vascular disease, poor performance, or signs of lower airway
disease.
Aortic Regurgitation
Murmurs of aortic regurgitation are holodiastolic and decre-
scendo with their point of maximal intensity located in the
aortic valve area, radiating to the left apex and to the right.
The murmurs range in grade from 1 to 6/6 and may be
blowing or musical.1,2,18 The musical murmurs are associated
with some portion of the aortic valve cusp fluttering in the
turbulent jet of aortic regurgitation. The detection of a
bounding arterial pulse is an indication that there is a signif-
icant left ventricular volume overload associated with the
aortic regurgitation.1,2,18 Aortic regurgitation is a common
degenerative valve disease that occurs in older horses.1,2,18
This murmur was not found in young Thoroughbred horses
before race training and was detected in only 2% of horses
following 9 months of race training.3
The aortic valve is frequently thickened, particularly the
left coronary cusp.1,18 The thickening may consist of a
nodular thickening in the center of the cusp, an echoic
thickening parallel to the free edge of the valve leaflet (Fig.
10), or may appear more diffuse (less common). A fenes-
tration of the valve leaflet is often present in horses with
musical holodiastolic decrescendo murmurs or the valve
leaflet can be torn at its free edge. Prolapse of the aortic
leaflet into the left ventricular outflow tract can also occur
and lead to aortic regurgitation. Vegetative endocarditis
lesions, although uncommon in horses, occur on the aortic
and mitral valve with nearly equal frequency.1,2,12,20 Irreg-
ular hypoechoic masses on the free edges of the valve
leaflets are seen with active bacterial colonization of the
valve with the lesions becoming more echoic, smoother,
and rounder as the infection resolves. Aortitis, in the ab-
sence of valvular endocarditis, has also been reported in a
V.B. Reef
horse with moderate to severe aortic regurgitation.21 High-
frequency vibrations are usually imaged on the septal leaf-
let of the mitral valve but may also be imaged on the
interventricular septum, depending on the direction of the
aortic regurgitation jet.1,18 Early systolic closure of the
mitral valve and an increased septal to E point separation
are also seen in horses with aortic regurgitation but did not
correlate with the severity of the regurgitation.2,18 Signifi-
cant aortic regurgitation causes left ventricular volume
overload and fractional shortenings of 50% to 65% can be
measured in horses with moderate to severe aortic regur-
gitation and normal left ventricular function (Fig. 11).1,2,18
The jet of aortic regurgitation should be interrogated from
both sides of the chest to attempt to align the ultrasound
beam as parallel as possible to the regurgitant jet. The
pressure half-time (time it takes for the velocity of the
regurgitant jet to decrease by half) is an indication of the
hemodynamic significance of the aortic regurgitation jet
(Fig. 12). A short pressure half-time (steep slope of the
aortic regurgitation jet) is associated with severe aortic
regurgitation and a rapid rise in left ventricular pressure.1,2
In horses with long-standing moderate or severe aortic
regurgitation, the aortic root gradually enlarges.1,2,18 The
left atrium also enlarges in horses with moderate or severe
aortic regurgitation, initially without the development of
significant mitral regurgitation.1
Most horses with aortic regurgitation have a normal per-
formance life and life expectancy since the regurgitation usu-
ally does not begin until the horse is older, is slowly progres-
sive, and the normal left ventricle can compensate well for the
left ventricular volume overload. A more guarded prognosis
should be given to horses with moderate to severe aortic
regurgitation that begins at an earlier age or in horses with a
flail aortic leaflet or a large bacterial endocarditis lesion.
Achieving a bacteriological cure is difficult and the progres-
sive scarring of the valve leaflet associated with the healing
endocarditis lesion usually leads to rapid worsening of the
aortic regurgitation.1,2,12
Figure 11 M-mode echocardiogram obtained from a horse with
moderate aortic regurgitation and a volume loaded left ventricle
(LV). Notice the swinging pattern of septal motion and the increased
fractional shortening consistent with a left ventricular volume over-
load. This echocardiogram was obtained from the right parasternal
window.
Echocardiography
Figure 12 Spectral tracing of a continuous wave Doppler echocar-
diogram obtained from a horse with moderate aortic regurgitation.
Notice the yellow orange jet of aortic regurgitation in the left ven-
tricular outflow tract in the color flow echocardiogram where the
spectral tracing was obtained. The slope of the spectral tracing dur-
ing diastole (arrows) is moderate, indicating the rate of rise of left
ventricular pressure associated with the aortic regurgitation. This
echocardiogram was obtained from the right parasternal window.
Indications for an
Echocardiogram in Horses
with a Continuous Murmur
Horses with continuous murmurs should always have an
echocardiogram performed, unless they are neonates and are
less than 96 hours of age. The ductus arteriosus does not
close in the foal until 96 hours of age. Pulmonary hyperten-
sion and pneumonia in foals can lead to the persistence of
flow through a patent ductus arteriosus (PDA) and the detec-
tion of a continuous machinery murmur for longer than 4
days post partum. The detection of a PDA in an older horse is
rare, however. The main differential for a continuous mur-
mur in an adult horse is an aortic cardiac fistula.
PDA
The murmur of a PDA is a continuous machinery murmur
that has its point of maximal intensity in the left third to
fourth intercostal spaces below the level of the point of the
shoulder. The murmur is usually a grade 3 to 6/6 and radiates
widely over the cardiac silhouette. The arterial pulses are
bounding. A PDA is a rare condition in horses, and if this
murmur is detected, more complex congenital cardiac dis-
ease should be suspected that includes a PDA. A PDA is more
likely in a premature foal or a foal with persistent pulmonary
hypertension. A dam that has been given prostaglandin in-
hibitors before parturition may also be more likely to have a
foal with a PDA. A PDA will cause an overload of the pulmo-
nary artery, left atrium, and left ventricle. Visualizing the
actual ductus is difficult due to overlying lung and is most
likely from the left cardiac window. High-velocity turbulent
flow directed toward the main pulmonary artery may be de-
tected with Doppler echocardiography associated with the
left to right shunt.
281
Aortic Cardiac Fistula
A continuous machinery murmur has been described in
nearly all horses in which an aortic cardiac fistula has been
diagnosed.1,22,23 The murmur is usually loudest in the right
third to fourth intercostal space. The murmur may radiate
out the aorta and is heard on the left side of the thorax as well.
The aortic cardiac fistula may be associated with an aneurysm
of the right sinus of Valsalva or with a tear in the right side of
the aortic root.1,22,23 The aneurysm in the right sinus of Val-
salva is usually just above in the inflow portion of the inter-
ventricular septum, best visualized in the left ventricular out-
flow tract view or in the short axis view of the aorta (Fig. 13).
An unruptured aneurysm appears as thin hypoechoic to
echoic tissue bulging into the right side of the heart. Usually
the aneurysm bulges into the right ventricle, although the
aneurysm can involve the tricuspid valve or right atrium.
Once ruptured, the aneurysm is imaged as thin hypoechoic
to echoic tissue fluttering in the right side of the heart, again
usually in the right ventricle. The aneurysm may also rupture
through the tricuspid valve or into the right atrium. Often
there is a hypoechoic tract of blood dissecting apically sub-
endocardially in the interventricular septum, usually on the
right side of the septum. Although aneurysms of the sinus of
Valsalva often occur with other congenital defects in human
beings, only one report of a horse with a ruptured sinus of
Valsalva aneurysm and an outflow tract VSD exists.23 Rup-
ture of the aortic root, in the absence of an aneurysm of the
sinus of Valsalva, appears as a defect in the right side of the
aortic root, usually at the junction of the aortic root with the
interventricular septum. A continuous shunt from left to
right is present in horses with an aortic cardiac fistula.
Indications for an
Echocardiogram in
Horses with Pericardial Friction
Rubs or Muffled Heart Sounds
An echocardiogram is always indicated in horses with peri-
cardial friction rubs or heart sounds that are significantly
Figure 13 Two-dimensional echocardiogram of a horse with an aor-
tic aneurysm. Notice the bulging of the aortic root at the right sinus
of Valsalva into the right ventricle at the level of the tricuspid valve
(arrow). This echocardiogram was obtained from the right paraster-
nal window. AR, aortic root; PA, pulmonary artery; LA, left atrium.
282
muffled to further characterize the underlying disease and its
severity. Pericardial friction rubs usually indicate inflamma-
tion within the pericardial sac with little or no fluid accumu-
lation, although occasionally rubs synchronous with the
heart beat can also be produced between the pericardium and
pleura. Muffled heart sounds usually indicate that a large
pericardial effusion is present, although the heart sounds can
be muffled for other reasons, such as in really fat horses.
The classic pericardial friction rubs are triphasic, but bi-
phasic and monophasic rubs can also be detected. Echocar-
diographic examination of horses with pericardial friction
rubs usually reveals rough erratic movement between the two
inflamed pericardial surfaces, synchronous with the rubs
ausculted. A small amount of increased fluid may be imaged
in the pericardial sac, usually ⬍2 cm. Echocardiographic
examination with a high-frequency transducer (5.0 MHz or
greater) can often improve the resolution and enable the
echocardiographer to visualize a small amount of fibrin in the
pericardial sac. With muffling of the heart sounds, the peri-
cardial sac is usually filled with a large quantity of fluid (Fig.
14), and pericardial drainage is indicated if the echocardio-
graphic examination confirms the presence of a large pericar-
dial effusion. Hypoechoic strands of fibrin are frequently
seen in horses with pericarditis.1,24,25 Large volumes of fluid
surrounding the heart can compromise cardiac filling, creat-
ing cardiac tamponade. With cardiac tamponade there is sys-
tolic collapse of the right atrium and diastolic collapse of the
right ventricle.1,24,25 Respiratory variations in right ventricu-
lar dimensions are also detected. The echocardiogram can aid
in the successful placement of the pericardial catheter for
drainage and pericardial lavage and can be used to monitor
the response to therapy. Treatment of horses with effusive
pericarditis with pericardial drainage and lavage has mark-
edly improved the prognosis, with all treated horses return-
ing successfully to their previous performance and none de-
veloping constrictive pericarditis.25 The base of the heart
should be carefully examined in all horses with pericardial
Figure 14 M-mode echocardiogram of both ventricles obtained from
a horse with pericardial effusion. Notice the anechoic space sur-
rounding the right and left ventricular free walls (black arrows), the
diastolic collapse of the right ventricle and the variation in right
ventricular filling associated with respiration. The right ventricle
(RV) and left ventricle (LV) are decreased in size due to impaired
filling. This echocardiogram was obtained from the right parasternal
window.
V.B. Reef
Figure 15 M-mode echocardiogram of both ventricles obtained from
a horse with cardiomyopathy. Notice the marked decreased in
thickening of the interventricular septum and left ventricular free
wall during systole associated with severe systolic dysfunction. This
echocardiogram was obtained from the right parasternal window.
RV, right ventricle; LV, left ventricle.
effusion for masses that could indicate a neoplastic etiology of
the pericardial effusion. The masses associated with pericar-
dial mesothelioma appear hypoechoic and resemble orga-
nized fibrin. Pericardial lymphosarcoma can also result in
muffling of the heart sounds, with diffuse infiltration of the
pericardium with neoplastic lymphocytes creating a thick
echoic pericardium overlying the heart.
Indications for an
Echocardiogram in
Horses with Suspected
Myocardial Dysfunction
An echocardiogram is indicated in all horses with poor per-
formance unrelated to other body systems and in all horses
exposed to ionophores. Cardiac auscultation may be normal
in these horses because myocardial dysfunction can occur in
the absence of valvular heart disease and/or cardiac arrhyth-
mias. Poor global left ventricular function and a fractional
shortening of ⬍30% are indicative of myocardial dysfunction
(Fig. 15). Cardiac chamber sizes may be normal, or mild
increases in left ventricular internal dimension at end diastole
and end systole may be noted. As the myocardial dysfunction
becomes more severe, dilation of the mitral annulus occurs
followed by mitral regurgitation and left atrial enlargement.
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