Today’s case is a 5 month old Labrador Retriever who presents for evaluation of a heart murmur. Take a look and post your comments!
5 month old Labrador Retriever
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{ 14 comments… read them below or add one }
In all the projections is visible that the aortic arch is bulging, the others cardiac chambers looks to be normal in size. The pulmonar vasculature is normal
The area of the MPA and aortic arch is prominent on the lateral view.
On the VD it seems that the prominence is of the aortic arch.
The left ventricle seems also to be slightly enlarged.
These findings are suspicious for aortic stenosis
There is a bulge in the craniodorsal border of the cardiac silhouette which is more discernible on the left lateral projection. Anatomical location corresponds to main vessels.
Both cranial and caudal pulmonary arteries and veins are dilated, suggesting pulmonary hypertension. There are no signs of pulmonary edema at the moment. Tracheal silhouette sing is probably due to the slight amount of gas in the esophagus.
Left ventricle seems to be enlarged as the caudal cardiac border appears upright and ventral deviation of the trachea is lost. Left atrium could be also enlarged slightly.
On the dorsoventral view, cranial mediastinum is bulged at 11 to 1 o’clock on the clock face of the heart which is displacing the trachea more to the right.
Mass effect could be produced by the dilation in the aortic arch as a result of patent ductus arteriosus and probably a left to right shunt. Valvular and subvalvular stenosis of the aortic arch should also be considered.
Echocardiography is recommended to confirm chamber enlargments or stenosis of the valve. Do an angiogram to rule out possible vascular shunt.
There is a bulging at the cardiac cranial waist and left atrial enlargement. The pulmonary veins are at upper limit of normality, however, the veins are more proeminent than the pulmonary arteries. Aortic stenosis with mitral insuficiency?
I will be swimming against the tide here, but I have to give the cardiac enlargement to the right side – it is not profound enlargement, however.
There is no serious amount of left atrial enlargement in my opinion … on the left lateral I thought “maybe” slight LA enlargement, but it could not be confirmed on the other views. I am going with right heart enlargement after all.
To me – the great vessel bulge is in the MPA – I can see a uniform and normal contour of the aorta in this DV.
Pulmonary vessels will be the key to diagnosis in this case. There is clearly a difference between pulmonary veins and arteries here. To me – the veins are larger than arteries … so that suggests that they are probably not both enlarged.
And this begs the question: Are the veins too large or are the arteries too small?
The answer to this question is very important to the diagnosis … what do you think? Of course – echo would also give us the diagnosis, but cardiologists are so busy. Perhaps we can spare them the trouble in this case … maybe.
But Dr Z didn’t post this case unless she had an echo to confirm what she thought was going on
Dan
I forgot – I agree there is gas in the esophagus. A little more than I would want to see, but this kid seems to be eating pretty well and I don’t here any issues suggesting a regurgitation problem. Perhaps he was upset at being restrained for imaging.
Dan
Well, I agree with Dan. On VD the aorta has normal contour. It makes me think of enlarged MPA. The cranial lobar arteries are smaller than veins, although I don’t see it on caudal lobar vessels. Also I think there is no cardiac chamber enlargement. It looks enlarged, but I think it’s because of the conformation of the thorax of this animal. A small amount of gas in the thoracic esophagus is likely due to aerophagia during radiography.
So..pulmonic stenosis would be on top of the list.
I disagree with Dan and radiovet74. To me this is very typical of post stenotic dilation of the aorta due to aortic stenosis. There is also mild left atrial dilation with could be due to functional mitral insufficiency that can be seen in aortic stenosis due to remodeling of the papillary muscles secondary to concentric hypertrophy of the left ventricle and papillary muscles where the chordae tendinae attach. I do not think a septal defect or PDA are present as I do not see evidence of hypervascularisation of the lungs. If what is seen on the lateral view were the MPA I certainly would expect to see a bulge at 1-2 o’clock on the VD. In addition, the hat sign described by Dr Buchanan should be seen on the lateral view which I don’t see on these radiographs.
Thanks for all the great comments! I think this kind of discussion brings out the points of what we all need to make our decisions on in a particular case. Feel free to ask your VR colleagues questions too, there’s a wealth of knowledge out there. And yes, Dan, I do post cases that have answers! It’s more fun that way. Though that shouldn’t stop you from telling a great story from the radiographs
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You are all on the right track with congenital cardiac disease as the main differential. So to sort out which one, we need to figure out which vessels and which part of the cardiac silhouette are abnormally enlarged.
For a PDA, as Dan said, we would be looking for an enlarged pulmonary artery, and left sided cardiac enlargement, as well as signs of overcirculation (enlarged pulmonary arteries and veins). To do this we rely on normal references such as looking at the vessel sizes in relation to each other, to other structures on the radiograph (eg. ribs), and to our “normal” reference database which is all the images in our radiographic experience. I don’t think there is any true cardiac enlargement, but there is a bulge at the cranial cardiac silhouette on the lateral. On the v/d it’s a bit less obvious because the enlargement is all cranial, not off to the side like an enlarged pulmonary artery. To me the position on the lateral can only be the aorta. I agree the cranial lobar vein is a little bit larger than the artery but they are both within normal limits for size. Here’s a case of PDA to compare the vessels and the heart with. And here is a normal thorax as well. Eastcoastrad brought up Dr. Jim Buchanan’s work on PDA. I can’t find the reference that describes the radiographic signs – anyone else? There are some great images from Dr. Buchanan archived on VIN and I have one reference that goes into the etiology of PDA.
1. Buchanan JW, Patterson DF. Etiology of patent ductus arteriosus in dogs. J Vet Intern Med 2003;17:167-171.
OK – you talked me into this being a bulge of the aortic root. And I can easily agree there is no significant cardiac enlargement.
Like radiovet74, I originally leaned toward pulmonic stenosis being the problem or at least part of the problem. I thought we should account for the lobar PAs being a bit small and I still think I see a bump on the MPA in this DV image.
Dr Z – in the PDA case you linked, there is a small bump on the aortic arch. I can see how this is different from the case being discussed.
I sure hope this patient will have an echo soon
Dan
Soooooooooooo, in the end, is this an aortic stenosis or a pulmonic stenosis??? I still think this is an aortic stenosis but could not see the answer yet in the case….
Sorry Dan, I misunderstood where you were going! This dog did go for an echo in the end and was diagnosed with severe subaortic stenosis and mild aortic insufficiency.
Thanks Dr Z.
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