Comparison of different radiographic scores with associated echocardiographic measurements and prediction of heart enlargement in dogs with and without myxomatous mitral valve disease

IntroductionStaging of myxomatous mitral valve disease (MMVD) requires an echocardiographic examination along with thoracic radiographs. The aims of this study were to calculate mean values for radiographic scores vertebral heart size (VHS), left atrial width (LA_Width), radiographic left atrial dimension (RLAD), and vertebral left atrial size (VLAS) in conventional and grayscale inverted images in healthy dogs and dogs with different stages of MMVD, and to find cutoff values for a stage assignment.AnimalsOne hundred fifty dogs in different stages of MMVD and 50 unaffected dogs were evaluated.MethodsRadiographic scores, echocardiographic left atrium-to-aorta ratio and normalized left ventricular internal dimension at end-diastole, and results of a clinical examination were obtained. Analyses were performed to evaluate the correlation between radiographic scores and echocardiographic values, to determine cutoff values for a radiographic stage assignment, and to compare measurements in conventional and inverted radiographs.ResultsAfter excluding breed-specific higher VHS, the means of VHS, LA_Width, RLAD, and VLAS were similar in the control group and stage B1. All radiographic scores increased in stages B2 and C. The cutoff values identifying heart enlargement, and therefore differentiating stages B1 and B2, were 11.0 for VHS, 1.8 for LA_Width, 2.0 for RLAD, and 2.3 for VLAS. Besides RLAD, scores were similar in conventional and inverted radiographs.ConclusionCutoff values for the different radiographic scores for stage assignment were calculated. Radiographic cardiac scores using either conventional or inverted grayscale could be a tool to differentiate between different stages of MMVD when echocardiography is unavailable.     

Caudal pulmonary artery to vein ratio on radiography can predict pulmonary hypertension in dogs with mitral regurgitation

Pulmonary hypertension (PH) is an important predictor of poor outcomes in dogs with mitral regurgitation (MR). The feasibility of radiography to predict PH in dogs with MR is unknown. This retrospective, observational, and analytic study aimed to identify a radiographic parameter to predict PH in dogs with MR. A total of 302 dogs diagnosed with MR on echocardiography were enrolled. Medical record and radiographic findings such as the size of the main pulmonary artery, left atrium, left ventricle, and right chamber, and cranial and caudal pulmonary arteries and veins were evaluated according to the presence of PH. The diameters of the cranial and caudal pulmonary vessels were compared to the fourth rib and the ninth rib, respectively, and the ratio of the pulmonary artery to the corresponding vein (CdPA/CdPV) was calculated. Pulmonary hypertension was diagnosed in 77 dogs (25.5%) and the prevalence of PH increased with MR grade. The CdPA/CdPV was significantly higher (P < 0.001) in the presence of PH. Multivariate analysis showed that the CdPA/CdPV was the only independent radiographic parameter that had a significant association with PH in dogs with MR (P = 0.028). The cut-off value of the CdPA/CdPV = 1.10 showed 90.6% specificity and 31.1% sensitivity for detecting PH in dogs with MR. In dogs with MR, PH can be predicted with high specificity when the caudal pulmonary artery is 1.1 times larger than the corresponding vein on radiographs.     

ACVIM consensus guidelines for the diagnosis and treatment of myxomatous mitral valve disease in dogs

This report, issued by the ACVIM Specialty of Cardiology consensus panel, revises guidelines for the diagnosis and treatment of myxomatous mitral valve disease (MMVD, also known as endocardiosis and degenerative or chronic valvular heart disease) in dogs, originally published in 2009. Updates were made to diagnostic, as well as medical, surgical, and dietary treatment recommendations. The strength of these recommendations was based on both the quantity and quality of available evidence supporting diagnostic and therapeutic decisions. Management of MMVD before the onset of clinical signs of heart failure has changed substantially compared with the 2009 guidelines, and new strategies to diagnose and treat advanced heart failure and pulmonary hypertension are reviewed.     

Value of tracheal bifurcation angle measurement as a radiographic sign of left atrial enlargement in dogs

An increased tracheal bifurcation angle on the dorsoventral projection is described as a sign of left atrium enlargement in dogs, with a normal range of 60-90 degrees reported. However in people, this angle is a poor indicator of left atrial size. Our purpose was to evaluate the value of the tracheal bifurcation angle for differentiating normal from enlarged left atrium in dogs. Dorsoventral radiographs and echocardiograms of 33 healthy and 73 dogs with confirmed degenerative myxomatous mitral valve disease were evaluated. Left atrial size was classified according to the echocardiographic left atrium to aorta ratio, as normal, mildly, moderately, or severely enlarged. Independent samples t-tests were used to compare the bifurcation angle between groups. A significant difference was observed between the angle of dogs with normal left atrium (68.1 +/- 8.5 degrees, range: 51.3-92.4 degrees) and dogs with enlarged left atrium (75.8 +/- 8.2 degrees, range: 57.3-91.7 degrees). A significant difference was also noted between the angle of normal dogs and those with moderate (75.5 +/- 6.8 degrees, range: 62.8-88.7 degrees) and severe (80.4 +/- 7.7 degrees, range: 64.7-91.7 degrees) left atrial enlargement, as well as between dogs with mild (70.7 +/- 7.2 degrees, range: 57.3-89.9 degrees) and severe enlargement. Using two discriminators, 85.1 degrees and 76.6 degrees, the bifurcation angle had a specificity of 92.6% and 88.9%, respectively, for identifying left atrial enlargement, and a sensitivity of 15.4% and 40.4%. Although significant differences were observed between dogs with normal and increased left atrial size, the large degree of overlap in the range of bifurcation angles and its poor sensitivity make the measurement of this angle of little value for diagnosing left atrial enlargement.     

Efficacy of enalapril for prevention of congestive heart failure in dogs with myxomatous valve disease and asymptomatic mitral regurgitation

We evaluated the long-term effect of early angiotensin-converting enzyme (ACE) inhibition (enalapril maleate) as monotherapy to postpone or prevent congestive heart failure (CHF) in asymptomatic dogs with mitral regurgitation (MR) attributable to myxomatous valvular disease (MVD) in a prospective, randomized, double-blinded, placebo-controlled multicenter trial involving 14 centers in Scandinavia. Two hundred twenty-nine Cavalier King Charles (CKC) Spaniels with MR attributable to MVD but no signs of CHF were randomly allocated to treatment with enalapril 0.25-0.5 mg daily (n = 116) or to placebo groups (n = 113). Each dog was evaluated by physical examination, electrocardiography, and thoracic radiography at entry and every 12 months (+/-30 days). The number of dogs developing heart failure was similar in the treatment and placebo groups (n = 50 [43%] and n = 48 [42%], respectively; P = .99). The estimated means, adjusted for censored observations, for the period from initiation of therapy to heart failure were 1,150 +/- 50 days for dogs in the treatment group and 1,130 +/- 50 days for dogs in the placebo group (P = .85). When absence or presence of cardiomegaly at the entrance of the trial was considered, there were still no differences between the treatment and placebo groups (P = .98 and .51, respectively). Multivariate analysis showed that enalapril had no significant effect on the time from initiation of therapy to heart failure (P = .86). Long-term treatment with enalapril in asymptomatic dogs with MVD and MR did not delay the onset of heart failure regardless of whether or not cardiomegaly was present at initiation of the study.     

Predictive model for the detection of pulmonary hypertension in dogs with myxomatous mitral valve disease

Pulmonary hypertension (PH) often occurs due to a left heart disease, such as myxomatous mitral valve disease (MMVD), in dogs and is diagnosed using Doppler echocardiography and estimated pulmonary arterial pressure. Diagnosis of PH in dogs requires expertise in echocardiography: however, the examination for PH is difficult to perform in a clinical setting. Thus, simple and reliable methods are required for the diagnosis of PH in dogs. The purpose of this study was to develop models using multiple logistic regression analysis to detect PH due to left heart disease in dogs with MMVD without echocardiography. The medical records of dogs with MMVD were retrospectively reviewed, and 81 dogs were included in this study and classified into PH and non-PH groups. Bivariate analysis was performed to compare all parameters between the groups, and variables with P values of <0.25 in bivariate analysis were included in multiple logistic regression analysis to develop models for the detection of PH. In multiple logistic regression analysis, the model included a vertebral heart scale short axis of >5.2 v, and a length of sternal contact of >3.3 v was considered suitable for the detection of PH. The predictive accuracy of this model (85.9%) was judged statistically adequate, and therefore, this model may be useful to screen for PH due to left heart disease in dogs with MMVD without echocardiography.     

Left atrial volume and function in dogs with naturally occurring myxomatous mitral valve disease

Objective

Myxomatous mitral valve disease (MMVD) induces progressive left atrial (LA) enlargement. The LA modulates left ventricular filling and performance through its reservoir, conduit, and contractile function. Assessment of LA size and function may provide valuable information on the level of cardiac compensation. Left atrial function in dogs with naturally occurring MMVD remains largely unexplored. The objective of this study was to evaluate LA volume and function in dogs with naturally occurring MMVD.

Dose-dependent effects of isoflurane and dobutamine on cardiovascular function in dogs with experimental mitral regurgitation

Objective

To investigate the dose-dependent effects of isoflurane and dobutamine on haemodynamics in dogs with experimentally induced mitral valve insufficiency (MI).

The ACVIM consensus statement definition of left ventricular enlargement in myxomatous mitral valve disease does not always represent left ventricular enlargement

ObjectiveTo determine how frequently the current criteria for left ventricular enlargement in dogs misclassify healthy dogs as having left ventricular enlargement; to examine the effect of breed on diastolic left ventricular normalized dimensions (LVIDDN); to propose appropriate scaling exponents and reference limits for dogs.AnimalsEchocardiographic data from 1,124 healthy adult dogs, including 454 dogs weighing <20 kg.MethodsWe calculated power regression parameters (allometric scaling), including exponents and proportionality constants, for various subsets of the dogs (all dogs, dogs < 20 kg, generic dogs, and individual breeds with >10 observations) and derived upper reference limits for LVIDDN. We determined the proportions of dogs that would be identified as having left ventricular enlargement with each regression model compared to previously published reference limits or guidelines. We then identified breeds failing to conform to generic dog models.ResultsThe American College of Veterinary Internal Medicine-recommended scaling exponent (0.294) and criterion for identifying left ventricular enlargement (1.7) identified >10% of apparently healthy dogs as having left ventricular enlargement, with specific breeds being misclassified up to 50% of the time. However, with a scaling exponent of 0.33, a constant of 1.7 represented a normal left ventricular size in 97.5% of healthy dogs in both generic and non-conforming breeds.ConclusionsLeft ventricular internal dimension in diastole normalized to bodyweight is breed-dependent. A constant of 1.7 with a scaling exponent of 0.294 does not always represent ventricular enlargement; a scaling exponent of 0.33, with breed-specific reference limits for breeds that fail to conform to allometric models of generic dogs, reduces the misclassification of healthy dogs as having left ventricular enlargement.     

Prevalence of mitral valve regurgitation in 79 asymptomatic Norfolk terriers

Objectives

To determine the prevalence of mitral valve regurgitation (MR) in asymptomatic Swedish Norfolk terriers.

Spectral analysis of heart rate variability in dogs with mild mitral regurgitation

OBJECTIVE: To assess autonomic function in dogs with mild mitral regurgitation (MR) that did not have clinical signs of the condition. ANIMALS: 6 healthy adult Beagles. PROCEDURE: Mild MR was experimentally induced. A 24-hour ambulatory ECG was recorded before and after induction of MR. Heart rate variability was analyzed in frequency domains by use of the ambulatory ECG. Low-frequency (LF) and high-frequency (HF) power were calculated by integrating over their frequency intervals, and the ratio of LF to HF was also calculated. Measurements of frequency domains were analyzed for 4 time periods (midnight to 6 AM, 6 AM to noon, noon to 6 PM, and 6 PM to midnight). RESULTS: Dogs with experimentally induced MR were classified as International Small Animal Cardiac Health Council class Ia. The HF power of dogs with MR was significantly decreased between 6 AM and noon. The ratio of LF to HF in dogs with MR was significantly increased for the periods between midnight and 6 AM, 6 AM and noon, and noon and 6 PM. CONCLUSIONS AND CLINICAL RELEVANCE: Compensatory response through autonomic modulation was observed in dogs with mild MR that did not have abnormalities, except for cardiac murmur, during clinical examination. This result suggests that treatment during the early stages of mild MR may be beneficial. Additional studies are necessary to determine whether such treatment will delay the onset of congestive heart failure and prolong survival in dogs affected with mild MR.