Jean-Louis Pouchelon

Diagnostic Value of Echo-Doppler and Tissue Doppler Imaging in Dogs with Pulmonary Arterial Hypertension

BACKGROUND Diagnosis of pulmonary arterial hypertension (PAH) relies on Doppler measurement of pulmonic and tricuspid regurgitation (TR). However, these are not always detectable. HYPOTHESIS Tissue Doppler imaging (TDI), a novel noninvasive ultrasound technique, provides indirect but sensitive and specific assessment of elevated systolic pulmonary artery pressure (SPAP) in dogs. ANIMALS One hundred and five dogs with TR. METHODS Prospective observational study. Dogs were categorized as presenting normal (group 1, n = 45), mildly increased (group 2, n = 19), or moderately to severely increased (group 3, n = 41) SPAP, based on TR peak velocities (< 2.5, 2.5-3.0, and > 3.0 m/s, respectively). Ten quantitative echo-Doppler- and TDI-derived variables were assessed, including the main pulmonary arterial diameter to aortic diameter ratio, pulmonary flow acceleration time, and acceleration-to-ejection time ratio, the Tei index of right ventricular function, and 6 longitudinal basal right ventricular TDI variables. RESULTS A significant correlation was observed between SPAP and each of the 10 tested variables (P < .05). Conventional echo-Doppler variables were less discriminating than the TDI for predicting increased SPAP. The combined systolic and diastolic right TDI index had the highest sensitivity and specificity (89% and 93% respectively, for a cutoff of 11.8 cm/s) and could discriminate between dogs in group 1 from dogs in group 2. CONCLUSIONS AND CLINICAL IMPORTANCE TDI provided effective predictors of systolic PAH and demonstrated that both alterations in right-sided systolic and diastolic myocardial function can occur with mild increases in SPAP.

Comparison of 3 Ultrasound Methods for Quantifying Left Ventricular Systolic Function: Correlation with Disease Severity and Prognostic Value in Dogs with Mitral Valve Disease

BACKGROUND End-systolic volume index (ESVI) is a marker of systolic function, which can be assessed by the geometric (GM, based on Teichholz formula) or 2 planimetric methods (PM, Simpsons derived and length area methods). HYPOTHESIS Systolic dysfunction (SyD) may be observed in dogs with mitral valve disease (MVD) and is better assessed by PM than GM, which does not take into account the longitudinal left ventricular systolic shortening. ANIMALS Six healthy dogs were used to determine the variability of the tested variables (Study 1). These variables were then prospectively assessed (Study 2) in 101 small breed dogs: 77 dogs with MVD and 24 healthy controls (CD). METHODS ESVI was measured by GM and PM in awake dogs. RESULTS All within- and between-day coefficients of variation were <11% (Study 1). For Study 2, a nonlinear overestimation of ESVI was observed by GM compared with PM. PM-derived ESVI was significantly increased in ISACHC class 3 dogs compared with ISACHC class 1 dogs and exerted a significant influence on cardiac events at 5 months in dogs with MVD from ISACHC classes 2 and 3 (P < .05). CONCLUSIONS AND CLINICAL IMPORTANCE ESVI can be calculated by GM and PM with good repeatability and reproducibility. However, GM overestimates ESVI in a nonlinear way. Therefore, PM-derived ESVI should be preferred for the detection of SyD that is present at the late stages of the disease.

Retrospective study of 942 small-sized dogs: Prevalence of left apical systolic heart murmur and left-sided heart failure, critical effects of breed and sex

OBJECTIVES The main goals of this study were (1) to carry out a retrospective study of the prevalence of left apical systolic heart murmurs, which are considered to clinically reflect the presence of MVD, in the 6 small canine breeds most popular in France, i.e., Yorkshire Terrier, Bichon Maltese, Dachshund, Poodle, Lhassa Apso and Shi Tzu and (2) to compare the results with those obtained in a recent report published by our group on MVD in 451 CKC. BACKGROUND Mitral valvular disease (MVD) has been extensively studied in Cavalier King Charles spaniels (CKC) but seldom studied and compared in other small-breed dogs. The first clinical sign of MVD is the early appearance of a left apical systolic heart murmur. ANIMALS Nine hundred and forty-two adult dogs were included in the present study (mean+/-SD, age=6.5+/-4.4 years, weight=6.2+/-2.6kg). RESULTS The average total prevalence of left apical systolic heart murmur was 14.4% compared with 40.6% in CKC. It was significantly more prevalent in males (18.5%) than in females (9.8%). Shi Tzu and Dachshunds were the most affected breeds investigated. Most (81%) of the dogs with left apical systolic murmur were classified in ISACHC heart failure class I. CONCLUSION This large retrospective study suggests that the prevalence of MVD is higher in CKC than in the 6 small breeds investigated. Moreover, most of the dogs do not develop congestive heart failure.

Plasma N-terminal pro-B-type natriuretic peptide concentration helps to predict survival in dogs with symptomatic degenerative mitral valve disease regardless of and in combination with the initial clinical status at admission.

OBJECTIVES Although mitral valve disease (MVD) is the most common canine heart disease, readily available prognostic markers of the disease are still lacking. The aim of this study was to evaluate the comparative ability of N-terminal pro-B-type natriuretic peptide plasma concentration (NT-proBNP) and various echocardiographic variables to predict outcome in dogs with MVD. ANIMALS, MATERIALS AND METHODS Seventy-four dogs with ISACHC classes 2 and 3 MVD (Groups A and B, respectively) were prospectively recruited. NT-proBNP and several echo-Doppler variables at inclusion were compared as predictors of outcome at 6 months in 54/74 dogs. RESULTS NT-proBNP was significantly higher in Group B than in Group A (P<0.0001), and was the only tested variable significantly different between survivor and non-survivor dogs in both groups (P<0.05). In the whole canine population, a threshold of 1500 pmol/L could discriminate survivor from non-survivor dogs with a sensitivity and specificity of 80% and 73%, respectively. When combining ISACHC class with NT-proBNP levels, a cut-off of 1265 pmol/L was predictive of survival in Group A, whereas the cut-off was 2700 pmol/L for Group B. CONCLUSIONS NT-proBNP is correlated with MVD severity and could be used in combination with clinical status to predict cardiac outcome.

Chordae tendineae Rupture in Dogs with Degenerative Mitral Valve Disease: Prevalence, Survival, and Prognostic Factors (114 Cases, 2001–2006)

BACKGROUND Degenerative mitral valve disease (MVD) is the most common heart disease in small breed dogs, and chordae tendineae rupture (CTR) is a potential complication of this disease. The survival time and prognostic factors predictive of survival in dogs with CTR remain unknown. HYPOTHESIS The prevalence and prognosis of CTR in dogs with MVD increases and decreases, respectively, with heart failure class. ANIMALS This study used 706 dogs with MVD. METHODS The diagnosis of CTR was based on a flail mitral leaflet with the tip pointing into the left atrium during systole, which was confirmed in several 2-dimension imaging planes using the left and right parasternal 4-chamber views. RESULTS CTR was diagnosed in 114 of the 706 dogs with MVD (16.1%) and most of these (106/114, 93%) had severe mitral valve regurgitation as assessed by color Doppler mode. CTR prevalence increased with International Small Animal Cardiac Health Council (ISACHC) clinical class (i.e., 1.9, 20.8, 35.5, and 69.6% for ISACHC classes Ia, Ib, II, and III, respectively [P < .05]). Long-term follow-up was available for 57 treated dogs (angiotensin-converting enzyme inhibitors and diuretics) and 58% of these (33/57) survived > 1 year after initial CTR diagnosis (median survival time, 425 days). Clinical class, the presence of ascites or acute dyspnea at the time of diagnosis, heart rate, plasma urea concentration, and left atrial size were predictors of survival. CONCLUSIONS AND CLINICAL RELEVANCE CTR is associated with a higher overall survival time than previously supposed. Its prognosis mostly depends on a combination of clinical and biochemical factors.

Ultrasonographic Assessment of Regional Radial and Longitudinal Systolic Function in Healthy Awake Dogs

BACKGROUND Strain (St) and strain rate (SR) imaging are new ultrasound modalities based on tissue Doppler imaging (TDI) that allow quantitative assessment of segmental myocardial contraction or stretching and rate of deformation, respectively. HYPOTHESIS Regional peak systolic St and SR could allow repeatable and reproducible assessment of systolic function of the right (RVW) and left (LVFW) myocardial walls in dogs. ANIMALS Six healthy Beagle dogs were used to determine the repeatability and reproducibility of regional peak systolic St and SR in the RVW and LVFW (Study 1). These variables were also assessed in 30 healthy dogs of several breeds (Study 2). METHODS Longitudinal peak systolic St and SR were recorded in 2 segments (basal and apical) of the RVW and LVFW. Radial peak systolic St and SR of the LVFW were also assessed. RESULTS All within- and most (7/10) between-day coefficients of variation were <15%. Absolute values of the longitudinal deformation indices were significantly higher (P < .001) in the RVW (St = -39.5 +/- 5.5% and SR = -5.2 +/- 0.8 s(-1) at the base; St = -36.3 +/- 4.3% and SR = -4.7 +/- 1.1 s(-1) at the apex) than in the LVFW. Absolute values were also higher for the radial (St = 62.9 +/- 10.4% and SR = 5.8 +/- 1.1 s(-1), P < .001) than for the longitudinal LFVW motions. CONCLUSIONS AND CLINICAL IMPORTANCE St and SR imaging is a repeatable and reproducible method for assessing systolic myocardial function. The combination of these indices with conventional echocardiographic variables may be useful for screening canine myocardial diseases.

Angiotensin-converting enzyme inhibitors in veterinary medicine.

Angiotensin-converting enzyme (ACE) inhibitors represent one of the most commonly used categories of drugs in canine and feline medicine. ACE inhibitors currently approved for use in veterinary medicine are benazepril, enalapril, imidapril and ramipril. They are all pro-drugs administered by oral route. A physiologically based model taking into account the saturable binding to ACE has been developed for pharmacokinetic analysis. The bioavailability of the active compounds from their respective pro-drug is low. The active metabolites are eliminated by renal, hepatorenal or biliary excretion, according to the drug. The elimination half-life of the free fraction of the active compounds is very short (ranging from approximately 10 min to 2 h). ACE inhibitors are generally well tolerated. Benazepril, enalapril, imidapril and ramipril are approved for dogs with chronic heart failure (CHF). The efficacy of ACE inhibitors has been convincingly demonstrated in dogs with CHF, especially in those with chronic valvular disease. In such clinical settings, ACE inhibitors improve hemodynamics and clinical signs, and increase survival time. In cats with cardiovascular disease, little information is available except for reports of some benefit in cats with hypertrophic cardiomyopathy in two non-controlled investigations. ACE inhibitors have also a mild to moderate hypotensive effect. There is also evidence to recommend ACE inhibitors in dogs and cats with chronic renal failure (CRF). They decrease the glomerular capillary pressure, have antiproteinuric effects, tend to delay the progression of CRF and to limit the extent of renal lesions.

Effect of benazepril on survival and cardiac events in dogs with asymptomatic mitral valve disease: a retrospective study of 141 cases.

BACKGROUND Angiotensin-converting enzyme inhibitors (ACEIs) improve quality of life and extend the life span of dogs with naturally acquired ISACHC class II-III congestive heart failure (CHF). However, their effects on asymptomatic heart disease remain controversial. HYPOTHESIS Benazepril (BNZ), an ACEI, could have beneficial effects at the asymptomatic stage of degenerative mitral valve disease (MVD). ANIMALS Dogs with ISACHC class Ia MVD and moderate-to-severe mitral regurgitation (MR) assessed by the color Doppler mapping technique at entry (Day 0) were retrospectively included. METHODS Dogs were assigned to the treated group (BNZ group) if they received BNZ (and no other cardiac medication) from Day 0 or to the untreated group (UT group) if they did not receive any cardioactive treatment until occurrence of CHF. RESULTS A total of 141 dogs were included in the study, 66 in the BNZ group (dosage: 0.30 +/- 0.13 mg/kg) and 75 in the UT group. In the population (n = 93) including all breeds except Cavalier (CKC) and King Charles Spaniels (KC), median survival time to all causes of death in the BNZ group (n = 34, 3.3 years) was significantly longer than in the UT group (n = 59, 1.9 years) as was time to cardiac event (P < .05). Conversely, no effect of the BNZ treatment was observed in the CKC and KC population. CONCLUSIONS AND CLINICAL RELEVANCE BNZ had beneficial effects in asymptomatic dogs other than CKC and KC affected by MVD with moderate-to-severe MR. Breed distribution should be taken into account for interpretation of clinical trials performed in dogs with cardiac disease.

Long-term tolerability of benazepril in dogs with congestive heart failure

OBJECTIVES To test the tolerability of long-term administration of benazepril in dogs with congestive heart failure (CHF). METHODS The study was a prospective, randomized, double-blinded, placebo-controlled clinical trial. A total of 162 dogs with New York Heart Association (NYHA) class II-IV heart failure caused by chronic valvular disease (CVD) or dilated cardiomyopathy (DCM) were enrolled. Benazepril (minimum dosage, 0.25 mg/kg) or placebo were administered orally once daily for up to 34 months. In this paper, we report results of plasma alanine aminotransferase (ALT), creatinine, potassium and urea. RESULTS The two groups were matched at baseline (p>/=0.18). Plasma creatinine concentrations were lower during treatment with benazepril versus placebo for all dogs (p=0.14) and every sub-group tested (NYHA II, III or IV; CVD; DCM; initial creatinine >124 mumol/L), although statistical significance was not reached (p=0.14-0.6). However, significantly (p=0.035) more cases of creatinine >124 mumol/L during treatment occurred with placebo (47%) as compared to benazepril (30%). Plasma ALT and urea values did not differ between groups for all dogs (p>0.5) or any sub-group (p=0.23-1.0). Plasma potassium values did not differ between groups for all dogs (p>0.5). Although differences approached statistical significance for potassium in some sub-groups (p=0.07-0.1), there were no consistent differences between groups. CONCLUSIONS Benazepril was well tolerated during long-term therapy in dogs with CHF and no specific precautions appear to be necessary regarding plasma ALT, creatinine, potassium or urea. The possible action of benazepril in improving renal function (evidenced via lower plasma creatinine) merits further investigation.

Comparison of Doppler ultrasonography and high-definition oscillometry for blood pressure measurements in healthy awake dogs

OBJECTIVE To determine the intra- and interobserver variability of systolic arterial pressure (SAP) and diastolic arterial pressure (DAP) measurements obtained with 2 indirect methods in awake dogs and percentage of successful measurements. ANIMALS 6 healthy conscious adult dogs. PROCEDURES 4 observers with different levels of training measured SAP and DAP on 4 days by use of Doppler ultrasonography (DU) and high-definition oscillometry (HDO). The examinations were randomized. Measurements for each technique were recorded 5 consecutive times, and mean values (total, 720 measurements) were used for statistical analysis. RESULTS All within- and between-day coefficients of variation (CVs) for SAP were < 15% irrespective of the observer or method (HDO, 3.6% to 14.1%; DU, 4.1% to 12.4%). Conversely, half the CVs for DAP were > 15% with the highest within- and between-day CVs obtained by the least experienced observer by use of DU (19.5% and 25.9%, respectively). All attempts with HDO were successful, whereas DAP could not be measured by use of DU by the least experienced observer in 17% of attempts. CONCLUSIONS AND CLINICAL RELEVANCE SAP may be assessed in healthy dogs by use of DU and HDO with good repeatability and reproducibility after a short period of training. Conversely, the variability of DAP is higher and longer training is required to assess DAP via DU than via HDO.