Aortic stenosis in the Dogue de Bordeaux

Objectives : To evaluate the occurrence of aortic stenosis and establish echocardiographic reference values in the Dogue de Bordeaux in Denmark. Methods : Fifty‐three dogs were auscultated for evidence of a cardiac murmur and a full echocardiographic examination was performed. The criterion for the diagnosis of aortic stenosis was a peak aortic velocity greater than 2·5 m/s from a subcostal transducer location. Results : A left‐basilar ejection murmur was detected in 38 (72 per cent) of the dogs. An aortic ejection velocity greater than 2·5 m/s was identified in 9 (17 per cent) of the dogs from a subcostal view. The aortic annulus in Dogue de Bordeaux was smaller than that considered normal in other breeds with comparable body size. Furthermore, a decreased aortoseptal angle was noticed in dogs with aortic stenosis. Clinical Significance : The Dogue de Bordeaux may be highly predisposed to aortic stenosis. The small aortic annulus noted in healthy and affected Dogue de Bordeaux and a decreased aortoseptal angle noted in affected dogs in this study might reflect key aetiological features in the development of aortic stenosis.     

Surgical correction of subvalvular aortic stenosis using cardiopulmonary bypass in a dog

A three-month-old male Golden Retriever had symptoms including exercise intolerance, dyspnea and syncope and was diagnosed with subvalvular aortic stenosis. Cardiac catheterization revealed a left ventricular-aortic systolic pressure gradient of 90 mm Hg. Surgical correction of the condition was achieved using cardiopulmonary bypass. The subvalvular fibrous lesion was resected through an aortotomy. The stenosis was dilated from 8.5 mm to 12.0 mm in diameter. Postoperatively the dog was asymptomatic. Seven months after surgery, the pressure gradient decreased to 44 mm Hg. However, after another three months, the dog died suddenly without any premonitory signs. Postmortem examination revealed that pathologic changes caused by increased left ventricular pressure overload were not severe.     

Closed Transventricular Dilation of Discrete Subvalvular Aortic Stenosis in Dogs

Discrete subvalvular aortic stenosis with peak systolic pressure gradients of more than 60 mm Hg was treated by closed transventricular dilation in six young dogs. Peak systolic pressure gradients were measured by direct catheterization before surgery, immediately after dilation, and 3 months after surgery. Maximum instantaneous pressure gradients were measured by continuous wave Doppler echocardiography before surgery and 6 weeks to 9 months after surgery. All dogs survived the procedure, and two dogs were clinically normal after 9 and 14 months. Two dogs died at week 6 and month 7. One dog was receiving medication for pulmonary edema 15 months after surgery. One dog underwent open resection of the subvalvular ring at month 3, and was clinically normal 6 months after the second procedure. Complications included intraoperative ventricular fibrillation in one dog, and mild postoperative aortic insufficiency in one dog. Closed transventricular dilation resulted in an immediate 83% decrease in the peak systolic pressure gradient from a preoperative mean of 97 +/- 22 mm Hg to a mean of 14 +/- 15 mm Hg. However, systolic pressure gradients measured by direct catheterization at month 3 (77 +/- 26 mm Hg), and by Doppler echocardiography at week 6 to month 9 (85 +/- 32 mm Hg) were not significantly different from preoperative values, which suggested recurrence of the aortic stenosis. Closed transventricular dilation should not be considered a definitive treatment for discrete subvalvular aortic stenosis in dogs, but may be useful in young dogs with critical aortic stenosis as a bridge to more definitive surgery.     

Clinical and pathological findings of severe subvalvular aortic stenosis and mitral dysplasia in a rottweiler puppy

Subvalvular aortic stenosis (SAS) and mitral dysplasia were diagnosed in an asymptomatic eight-week-old rottweiler. Clinical and pathological findings were compatible with a fixed and dynamic obstruction of the left ventricular outflow tract. Gross and microscopic pathological findings were consistent with the most severe form of SAS, described previously in Newfoundland dogs over six months of age. These observations demonstrate that very young asymptomatic puppies may suffer a severe complex form of SAS.     

Echocardiographic parameters in 14 healthy English Bull Terriers

OBJECTIVE: To determine the range of various cardiac parameters using echocardiography in apparently normal, healthy English Bull Terriers. DESIGN: Fourteen English Bull Terriers were selected for study. Cardiac auscultation of the parents of these dogs was normal. Echocardiographic examination of one parent of each animal showed: no mitral or aortic valve abnormalities; no myocardial lesions; no two dimensional evidence of fixed or dynamic left ventricular outflow tract obstruction; and no systolic aortic or left ventricular outflow tract turbulence on colour flow Doppler examination. The 14 selected dogs did not have arrhythmias or murmurs, and on echocardiographic examination had similar findings to their parents. Systolic blood pressure was measured in all dogs and they had no clinical evidence of Bull Terrier polycystic kidney disease or Bull Terrier hereditary nephritis. PROCEDURE: All dogs were auscultated and subjected to a sequential global echocardiographic assessment of the heart, including two dimensional long and short axis, and colour flow Doppler interrogation of the mitral and aortic valves. Dimensional measurements, including those from the left atrium, aortic annulus and left ventricle, were taken from a right parasternal window, and derived values such as fractional shortening, stroke volume and left atrial to aortic annulus ratio were calculated. Peak systolic aortic velocity was measured from the left parasternal window using two dimensional-guided pulsed wave Doppler with angle correction. Systolic blood pressure was measured using a Doppler monitor. The absence of Bull Terrier polycystic kidney disease was determined using renal ultrasonography, and of Bull Terrier hereditary nephritis using urinary protein to creatinine ratio. RESULTS: These 14 dogs had greater left ventricular wall thickness and smaller aortic root diameters than those reported as normal for other breeds of comparable body size. Left atrial dimensions were also larger, however this may have been due to the "maximising" method of measurement. These apparently normal English Bull Terriers also had higher aortic velocities than those reported for other breeds, possibly due to a smaller aortic root diameter or other anatomic substrate of the left ventricular outflow tract, lower systemic vascular resistance, or breed-specific "normal" left ventricular hypertrophy. While these dogs were selected to be as close to normal as possible, the breed may have a particular anatomy that produces abnormal left ventricular echocardiographic parameters. CONCLUSION: These echocardiographic parameters may be used to diagnose left ventricular outflow tract obstruction and left ventricular hypertrophy, and inaccurate diagnoses may result if breed-specific values are not used.     

COMPARISON OF DOPPLER-DERIVED AORTIC VELOCITIES OBTAINED FROM VARIOUS TRANSDUCER SITES IN HEALTHY DOGS AND CATS

In normal dogs and dogs with subaortic stenosis, it is known that the subcostal transducer site provides higher left ventricular ejection velocities than does the left apical site. We hypothesized that aortic flow velocities could also be obtained from the right parasternal long-axis view, optimized for the placement of the Doppler cursor as parallel as possible into the aortic root. In 15 healthy dogs and 13 healthy cats, high-pulsed repetition frequency Doppler flow velocity measurements in the proximal aorta were performed using two-dimensional echocardiographic guidance. The mean [ +/- standard error of the mean (SEM)] peak aortic flow velocities in healthy dogs were as follows: subcostal site 1.46 +/- 0.05 m/s; apical site 1.12 +/- 0.06 m/s; right parasternal long-axis site 1.09 +/- 0.05 m/s. In healthy cats, the following peak aortic flow velocities were observed: apical site 0.87 +/- 0.03m/s; right parasternal long-axis site 0.87 +/- 0.03 m/s. Aortic flow velocities obtained from the subcostal site were significantly higher in healthy dogs than those obtained from the left apical and right parasternal long-axis site (P< 0.001). There was no statistical difference between the peak aortic flow velocities obtained from right parasternal long-axis and left apical transducer position in all groups. We conclude therefore that right parasternal long-axis and left apical-derived aortic flow velocities are similar and may be used interchangeably in healthy dogs and cats.     

High-pressure balloon dilation in a dog with supravalvular aortic stenosis

A 6-month-old female intact Goldendoodle was presented for diagnostic work up of a grade IV/VI left basilar systolic heart murmur. An echocardiogram was performed and revealed a ridge of tissue distal to the aortic valve leaflets at the sinotubular junction causing an instantaneous pressure gradient of 62 mmHg across the supravalvular aortic stenosis and moderate concentric hypertrophy of the left ventricle. Intervention with a high-pressure balloon dilation catheter was pursued and significantly decreased the pressure gradient to 34 mmHg. No complications were encountered. The patient returned in 5 months for re-evaluation and static long-term reduction in the pressure gradient was noted.     

Low intensity heart murmurs in boxer dogs: inter-observer variation and effects of stress testing

Inter-observer variation in the detection and grading of low intensity heart murmurs in boxer dogs was investigated. Six veterinarians with different levels of experience examined 27 boxers by cardiac auscultation. The dogs were auscultated before and after exercise, and the results were compared with phonocardiographic and echocardiographic examinations performed at rest and during two different stress tests. A subvalvular aortic ridge was identified in six dogs on two-dimensional echocardiography. Using dogs with low intensity murmurs or dogs free of heart murmurs, inter-observer agreement was positively correlated to the level of experience at rest (weighted kappa [kappa] 0.14 to 0.75), while the agreement was poor after exercise (weighted kappa 0.01 to 0.36). The presence of a subvalvular aortic ridge was associated with higher aortic flow velocities (P<0.002) and higher auscultatory murmur grading (P<0.001). There was an increase in murmur duration during one kind of stress test (P<0.001) and in aortic flow velocity during the other (P=0.001).     

Resection of Subvalvular Aortic Stenosis Surgical and Perioperative Management in Seven Dogs

Open heart surgery was performed during cardiopulmonary bypass (CPB) to surgically correct subvalvular aortic stenosis in seven dogs. After initiation of total CPB, cardiac arrest was induced by antegrade and retrograde administration of blood cardioplegia. The subvalvular fibrous stenosis was resected through a transverse aortotomy. Intraoperatively and postop-eratively, dobutamine, nitroprusside, lidocaine, blood(-products), and crystalloid solutions were used to manage hypotension and optimize cardiac index.
Aortic cross-clamp time varied from 73 to 166 minutes, and duration of CPB varied from 130 to 210 minutes, latrogenic incision into the mitral valve in two dogs was the most significant introperative complication. Postoperative complications included: hypoproteinemia (n = 7), premature ventricular depolarization (n = 6), increased systemic vascular resistance index (n = 5), increased O₂ extraction (n = 3), pulmonary edema (n = 2), and decreased cardiac index (n = 1). All seven dogs were discharged alive and in stable condition. Six dogs are alive and in stable condition after a mean follow up of 15.8 months.
This is the first detailed report of CPB in a series of clinical veterinary patients. Using the techniques described in this paper, open heart surgery of considerable duration can be performed successfully in dogs with significant myocardial hypertrophy and endomyocardial fibrosis secondary to subvalvular aortic stenosis.     

Congenital supravalvular aortic stenosis in a kitten

A three-month-old, male intact Norwegian forest cat without any clinical signs was referred to the cardiology service of the author’s teaching hospital for evaluation of a cardiac murmur. The murmur was systolic with an intensity of 4 out of 6 with the point of maximal intensity at the left heart base. Echocardiography revealed a moderate mitral valve regurgitation and a moderate dynamic left ventricular outflow tract obstruction both resulting from systolic anterior motion of the mitral valve (SAM). Moreover, left ventricular concentric hypertrophy was noted. Oral atenolol therapy was initiated. Recheck examination 3.5 months later revealed unchanged murmur characteristics in the still asymptomatic kitten. Echocardiography showed no SAM, but there was a severe fixed aortic stenosis apparent caused by a discrete supravalvular lesion, 4 mm distal to the valve, with an hourglass morphology. Supravalvular aortic stenosis is a rare congenital anomaly in cats, which has not been reported antemortem yet.     

M-mode and Doppler echocardiographic reference values for male New Zealand white rabbits

OBJECTIVE: To determine M-mode and Doppler echocardiographic reference values in healthy New Zealand white rabbits. ANIMALS: 52 healthy male rabbits. PROCEDURES: The rabbits were anesthetized and M-mode measurements of the left ventricle, left atrium, and aorta and Doppler measurements of pulmonary and aortic outflow and mitral inflow were recorded. RESULTS: Mean +/- SD heart rate during echocardiographic examination was 155 +/- 29 beats/min. Mean +/- SD measurements in diastole and systole for the interventricular septum thickness, left ventricular internal diameter, and left ventricular free wall thickness were 2.03 +/- 0.37 mm and 3.05 +/- 0.45 mm; 14.37 +/- 1.49 mm and 10.25 +/- 1.22 mm; and 2.16 +/- 0.25 and 3.48 +/- 0.55 mm, respectively. Mean +/- SD left atrial-to-aortic diameter ratio was 1.17 +/- 0.14, and mean +/- SD mitral valve E-point-to-septal separation interval was 1.71 +/- 0.29 mm. Mean +/- SD for fractional shortening and ejection fraction were 30.13 +/- 2.98% and 61.29 +/- 4.66%, respectively. Mean +/- SD maximal aortic and pulmonary artery outflow velocities were 0.85 +/- 0.11 m/s and 0.59 +/- 0.10 m/s, respectively, and the peak E-to-peak A wave velocity ratio of the mitral valve was 2.19 +/- 0.46. CONCLUSIONS AND CLINICAL RELEVANCE: Results provide echocardiographic reference values for young adult male New Zealand white rabbits anesthetized with ketamine and medetomidine. Values obtained from unanesthetized rabbits, rabbits sedated with other agents, or rabbits of different size may differ from those reported here.     

Congenital mitral stenosis,subvalvular aortic stenosis,and congestive heart failure in a duck

A 2.6-year-old duck was evaluated for respiratory difficulty. On the basis of physical, radiographic and echocardiographic findings, a diagnosis of congestive heart failure secondary to congenital mitral stenosis and subvalvular aortic stenosis was made. The duck did not respond well to medical therapy and was euthanized. The diagnosis was confirmed at necropsy.     

Successful balloon angioplasty of pulmonary artery stenosis in two cats and associated complications

Two cats (2.5 months and 8 months old) were each evaluated due to a loud systolic murmur, and each was diagnosed with severe pulmonary artery stenosis at the bifurcation of the main pulmonary artery. Echocardiograms confirmed significant right atrial dilation and right ventricular dilation and/or hypertrophy that was progressive in one cat. Atenolol was initiated and the cats were referred for interventional therapy. Balloon angioplasty was performed via the jugular vein. In case 1, the pressure gradient across the stenosis was reduced from 169.7 mmHg to 23.6 mmHg and 52.4 mmHg across the left and right branch pulmonary arteries, respectively. In case 2, the stenotic echocardiographic gradient was reduced from 64 mmHg to 38.0 mmHg and 35.3 mmHg across the left branch and right-branched pulmonary arteries respectively. Both patients developed moderate to severe dynamic right ventricular outflow tract obstruction post angioplasty. Case 2 developed hypotension, desaturation, and ventricular arrhythmias intra-operatively. Case 1 was discharged but appeared to develop acute lung perfusion injury approximately 36 h after procedure that was manifested by radiographic pulmonary congestion and pulmonary infiltrate of the left lung fields. The congestion was successfully managed medically. Serial echocardiograms over the following 4 years in case 1 showed near complete resolution of the stenosis and associated right heart enlargement.     

Mitral valve dysplasia in a cat causing reversible left ventricular hypertrophy and dynamic outflow tract obstruction

A 6-month-old male European shorthair cat was examined because of a 2/6 systolic left apical cardiac murmur. Echocardiography revealed severe concentric left ventricular hypertrophy and severe dynamic left ventricular outflow tract obstruction (pressure gradient of 85 mmHg) caused by systolic anterior motion (SAM) of the septal mitral valve leaflet. After 2 months of oral treatment with atenolol, the cardiac murmur had disappeared. Echocardiography showed only slight thickening of the interventricular septum and resolution of the pressure gradient. The cat was discharged and its owner was advised to continue atenolol lifelong. Echocardiographic findings of a combination of left ventricular concentric hypertrophy and dynamic left ventricular outflow tract obstruction can be caused by hypertrophic obstructive cardiomyopathy (HOCM) or mitral valve dysplasia in the absence of hypertension and fixed aortic stenosis. In the case of HOCM, left ventricular hypertrophy is the primary process. In the case of mitral valve dysplasia, systolic anterior motion of the mitral valve is the primary problem, which leads to dynamic left ventricular outflow tract obstruction and ultimately to left ventricular concentric hypertrophy, due to pressure overload. If the left ventricular outflow tract obstruction is reduced with an oral beta-receptor blocker the secondary left ventricular hypertrophy may resolve. This would not happen in the case of hypertrophic obstructive cardiomyopathy. To the best of the authors' knowledge, this is the first documented case of severe dynamic left ventricular outflow tract obstruction and severe left ventricular hypertrophy in a cat successfully treated with oral atenolol.     

Dynamic obstruction of the left ventricular outflow tract in four young dogs

Four young dogs presented for evaluation of left-sided systolic heart murmurs all showed echocardiographic changes consistent with dynamic left ventricular outflow tract (LVOT) obstruction and subjective evidence of concentric left ventricular hypertrophy. In three of the dogs, abnormal mitral valve apparatus and systolic anterior motion of the anterior mitral valve leaflet with associated mitral insufficiency were also detected. All dogs were medicated with a beta1-adrenergic antagonist. Subsequent examinations showed that the dynamic LVOT obstruction and left ventricular concentric hypertrophy had almost completely resolved. Dynamic LVOT obstruction is a rare condition of young dogs of different breeds. The precise aetiology of the condition remains uncertain. Whether resolution of the outflow obstruction in these four cases was a consequence of treatment or due to changes in ventricular architecture brought about by ageing cannot be established.     

Surgical management of subvalvular aortic stenosis and mitral dysplasia in a golden retriever

A 12monthoid neutered male golden retriever was presented with a history of lethargy and exercise intolerance. Clinical examination, electrocardiography, radiography and echocardiography supported a diagnosis of fixed subvalvular aortic stenosis with a Doppler pressure gradient of 77.5 mmHg. Surgical inspection also revealed gross structural abnormalities of the mitral valve consistent with mitral dyspiasia. intervention consisted of resection of the dysplastic mitral valve and the subvalvular aortic stenosis. The mitral valve was replaced with a bioprosthetic valve. Total cardiopulmonary bypass time was 65 minutes and aortic crossclamp time was 55 minutes. A full recovery was made and 11 months postoperatively the aortic transvalvular gradient was 30 mmHg. At the time of writing, 12 months after surgery, the dog was clinically normal and requires no medication.     

The relationship of resting S-T segment depression to the severity of subvalvular aortic stenosis and the presence of ventricular premature complexes in the dog

Electrocardiograms (ECG) from 35 dogs with subvalvular aortic stenosis (SAS) with a left ventricular outflow tract pressure gradient (PG) of > or =50 mm Hg were retrospectively evaluated for S-T segment depression (STD, > or =0.2 mV in lead II). Pressure gradient, age, heart rate (HR), and number of ventricular premature complexes (VPCs) on a 24-hour ambulatory ECG for dogs with STD were not significantly different from those for dogs without STD. The S-T segment deviation did not correlate significantly with PG, age, HR, or VPCs. The significance of STD in the dog with SAS remains uncertain. Long-term prospective studies are needed to fully understand this observation.     

CAUDAL VENOUS RETURN THROUGH A LEFT AZYGOS VEIN IN A DOG

The Clinical, radiologic and echocardiographic findings in a one-year old dog with mild subvalvular aortic stenosis and aberrant caudal vena circulation are described. Aberrant systemic venous return to the right side of the heart usually has little clinical significance, but the unusual features in survey radiographs, contrast angiograms and contrast echocardiograms constitute the reasons for this report.     

Doppler echocardiographic effects of medetomidine on dynamic left ventricular outflow tract obstruction in cats

OBJECTIVE: To evaluate the effects of medetomidine on dynamic left ventricular outflow tract (LVOT) obstruction in cats with left ventricular hypertrophy. DESIGN: Clinical trial. ANIMALS: 6 domestic shorthair cats with echocardiographic evidence of dynamic LVOT obstruction. PROCEDURE: Cats were restrained in lateral recumbency, and baseline M-mode and Doppler echocardiographic examinations were performed. An ECG was recorded continuously, and blood pressure was measured indirectly with Doppler instrumentation. Medetomidine (20 microg/kg 19.1 microg/lb]) was then administered i.m., and examinations were repeated 15 minutes later. RESULTS: Significant decreases in heart rate, LVOT velocity, and the LVOT pressure gradient were documented following medetomidine administration. After adjusting for the effects of heart rate by ANCOVA, there were no significant differences in any other systolic or diastolic indices of left ventricular function. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that administration of medetomidine to cats with dynamic LVOT obstruction may result in elimination of outflow tract obstruction; medetomidine may be a suitable sedative and analgesic agent in this subpopulation of cats.     

Surgical treatment of severe pulmonic stenosis under cardiopulmonary bypass in small dogs

Objectives : The aim of this study was to report the long‐term outcome of the surgical palliation of pulmonic stenosis in dogs. Methods : The subjects comprised three female and six male dogs, mean (±sd) age: 23 (±25) months, mean (±sd) weight: 3·4 (±2·1) kg, diagnosed with severe pulmonic stenosis and right ventricular hypertrophy, with an average preoperative pressure gradient of 153 (±43) mmHg on echocardiography. Results : The pressure overload with severe pulmonic stenosis was reduced by valvotomy, i.e., open pulmonary valve commissurotomy, with/without biomembrane patch grafting, under cardiopulmonary bypass. The postoperative pressure gradient at 1 to 7 days was significantly decreased to 65 (±39) mmHg (P<0·05). The reduced pressure gradient was maintained at 58 (±38) mmHg at final follow‐up. Clinical Significance : Open valvotomy, pulmonary valve commissurotomy and biomembrane patch grafting were effective in reducing obstruction in severe pulmonic stenosis in dogs.