Chief EditorK.M.L. Pathak
Print ISSN 0367-6722
Online ISSN 0976-0555
NAAS Rating 6.43
Impact Factor 0.5 (2023)
Full Research Article
A Ten Year Retrospective Study on Cor Triatriatum Sinister Associated Heart Failure in Dogs
- Email firstname.lastname@example.org
Methods: The dogs were examined clinically, physically and later subjected for chest radiograph and echocardiography to confirm CTs. All were showing regular femoral pulse that was strong and synchronous to the heart beat, pale mucosa, mean systolic arterial blood pressure of 145 mm Hg and with normal hemato-biochemical parameters. Cardiomegaly with increased sternal contact, elevated trachea, pulmonary congestion and engorged caudal vena cava were radiographic findings. 2d-echocardiography revealed a left atrium that was subdivided by a transverse membrane into two distinct compartments, one proximal and one distal, thus confirming the cortriatriatum sinister.
Result: Cor triatriatum sinister (CTs) was diagnosed in 4 dogs with a prevalence of 4.59% amongst those suffering from congenital heart anomalies, that were aged between 5y-7y and the breeds include Boxer, Doberman and Cocker spaniel. All these dogs were presented with similar signs suggestive of heart failure viz., exercise intolerance, dyspnoea at rest, cough that was dry nocturnal type, generalised weakness and syncope. All of these patients were successfully managed with frusemide, benazapril and pimobendan. Hence, it may be concluded that the CTS, a rare congenital cardiac anomaly in dogs should also be included in the differential diagnosis of heart failure, particularly if presented at early life, which also helps to prevent further breeding from such stock.
MATERIALS AND METHODS
2dimensional echocardiography was performed in right lateral recumbancy as right parasternal transthoracic echocardiograms in non-sedated dogs suspected for CTs. Access to the right side of the thorax was facilitated by using a table with a special cut-open to allow the transducer to be directed upward towards the site of maximal cardiac pulsation (Allworth et al., 1995). Transducer is located parasternally between right third and sixth intercostal spaces between sternum and costochondral junction (Thomas et al., 1994). M-mode recordings were taken at the high papillary level and themeasurement of left ventricular dimension at end–diastole (LVEdD) and end-systole (LVEsD) was made intraluminally from the trailing edge of the septal wall image to the leading edge of the ventricular free wall. End-diastolic and end–systolic measurements of the thickness of the Inter Ventricular Septum (IVSd, IVSs) and left Ventricular Posterior Wall (LVPWd, LVPWs) were made using trailing edge (AllWorth et al., 1995). Further, colour flow Doppler was also done to assess the directional flow as per the technique suggested by Dominique and Marc-Andre (2008).
RESULTS AND DISCUSSION
During the present investigation, a total of 795 dogs were diagnosed for various acquired (89%) and congenital cardiac diseases (11%), accounting for 708 and 87 cases, respectively. Out of the total congenital diseases (87), cortriatriatum sinister (CTs) was diagnosed in 4dogs (4.59%), aged between 5-7 years amongst Boxers (2), Doberman (1) and Cocker spaniel (1) breeds. Congenital anomalies of the cardiovascular system are defects present at birth and often lead to perinatal death in dogs. However, in some cases, congenital heart diseases (CHDs) are asymptomatic and undetected until later in life, so the percentage of dogs with congenital heart diseases that survive to adulthood to breed can be rather high (Garncarz et al., 2017 and Caivano et al., 2018). Bulldog and Boxers are reportedly common affected breeds (Gustavo et al., 2012). The difference in the prevalence of CHDs depends on the popularity of the breed in a country in a given period of time (Ghirlanda et al., 2014). Knowing the epidemiology of CHDs plays an important role in maintaining dog health and in preventing the diffusion of CHDs in the dog population (Garncarz et al., 2017). Cor triatriatum is among the rarest developmental anomalies of cardiovascular system reported in humans (Hamdan et al., 2010) followed by dogs and cats (Cote, 2011). Cor triatriatum can be either, sinister or dexter that result from a fibrous membrane dividing the left or right atrium, respectively. Cor triatriatum dexter (CTd) is thought to account for only 0.1% of human congenital heart disease and only 0.3% of canine congenital heart disease (Bruce, 2015). While CTd has been well described in the dog, historically, CTs was first described in human beings (Church, 1868) and later after more than a century in the veterinary patients. The first ever case was reported in a cat (Gordon et al., 1982). Among dogs, cortriatriatum dexter has been reported earlier (Tobias et al. 1993; Kittleson, 1998; Mitten et al., 2001; Oliveira et al., 2011) and CTs quite recently (Gustavo et al., 2012).
Clinical presentation of CTs
All the dogs diagnosed for CTs were presented with similar history and signs suggestive of heart failure viz., exercise intolerance, dyspnoea at rest, cough- particularly dry nocturnal type that was ignited by physical activity and deep sleep, generalised weakness. Syncope was additionally reported in the Cocker spaniel. Physical examination revealed,a considerably elevated heart rate and a femoral pulse that was regular, strong and synchronous to the heart beats. Auscultation revealed a soft systolic murmur on left heart base (75%), tricuspid area (50%) and pulmonic valve area (25%), withmoderately distended jugular vein (50%) and jugular pulse (50%). The details are given in Table 1. Rectal temperature was within the normal range among all the affected cases, slightly pale conjunctival mucous membrane. The averagesystolic arterial blood pressure that was recorded among these dogs, using Doppler blood pressure (BP) machine was 145 mm Hg. Mild neutrophilia, normal BUN and serum creatinine values were observed. Radiographic abnormalities noticed on right lateral thoracic radiograph included cardiomegaly, increased sternal contact, elevated trachea, pulmonary congestion and engorged caudal vena cava (Fig 1). Though cortriatriatum sinister is a well-documented cardiac malformation among humans, published reports amongst canines are rare (Castagna et al 2019). CTs affected dogs and cats are presented with the signs of left heart failure, with pulmonary edema, pleural effusion, or both (David, 2016). The pathophysiology and complications of CTs are variable and depends whether it is an isolated defect or associated with other cardiovascular anomalies, including the size of the membrane’s orifice (Kelmendi et al., 2009). If the anomalies remain associated with other cardiovascular defects or if the foramen is too large, the prognosis might be serious (Nassar and Hamdan, 2011; Lima et al., 2010; Sandra, 2020).
Echocardiographic features of CTs
Right parasternal 2d-echocardiography revealed a left atrium that was subdivided by a transverse membrane into two distinct compartments, one proximal and one distal, thus confirming the cortriatriatum sinister (Fig 2). Dilatation of right atrium, right ventricle and thickened right interventricular septum with normal interatrial septum were also noticed (Fig 3 and 4). The mitral valve did not reveal any abnormality, but billowing of the tricuspid valve was noticed (Fig 5). Pulse wave Doppler at mitral area showed laminar flow and regurgitant flow with turbulence jet was seen at the tricuspid valve area (Fig 6 and 7). Mild pulmonary valve regurgitation was also noticed on the right parasternal 4-chamber short-axis view. The presence of obstructive membrane in the left atrium leads to increased pulmonary venous capillary pressure resulting in pulmonary edema, congestion and pulmonary hypertension (Gordon et al., 1982; Oliveira et al., 2011). 2d-echocardiography is the most promising procedure to confirm the anomaly (Thakrar et al., 2007; Nassar and Hamdan, 2011; Menaut et al., 2009). As the disease progress, subsequently there will be enlargement of left proximal atrial chamber and main pulmonary artery, thereby resulting in dilatation of right atrium and right ventricle resulting in eccentric hypertrophy (Cote et al., 2011).
Management of HF associated with CTs
Following treatment with diuretic (frusemide), ACE inhibitor (benazepril) andinotropic agent (pimobendon), all the CTs dogs showed improvement in overall physical activity from day 10. There was alleviation in dyspnoeathat improved to near normal breathing pattern, absence of cough, improvement in physical activity, energy levels with exercise tolerance levels and normal appetite by day 20, following therapy. Like any other heart failure, CTs dog can also be managed with beneficial effects using diuretics and angiotensin converting enzyme inhibitors (Gordon et al., 1982; Macdonald, 2006; Gustavo et al., 2012). Diuretics is the primary drug in the management of heart failure, as it reduces preload and relieves congestion secondarily to cardiac dysfunction. However, diuretics should never be used as single therapy as they activate Rennin Angiotensin Aldosterone System (RAAS), therefore they should be used in conjunction with ACE inhibitors (Sandra, 2020). BENCH Study Group (1999) reported the effect of a long acting ACEi and benazepril on the survival times and clinical signs of dogs with heart failure and documented that the drug counteracts the adverse effects caused by ACE activity in heart failure. In the present study, the combination therapy significantly improved the clinical signs such as, breathing, physical activity and exercise strength and duration subsequently resulting in prolonged survival time.
Conflict of interest
- Allworth, S.M., Church, D.B., Maddison, J.E., Einstein, R. and Brennar, P. (1995). Effect of enalapril in dogs with pacing induced heart failure. American Journal of Veterinary Research. 56: 86-94.
- BENCH (BENazepril in Canine Heart disease) Study Group, Pouchelon, J.L., King, J., Martignoni, L., Chetboul, V., Lugardon, B., Rousselot, J.F., Corlouer, J.P., Bussadori, C., Piette, M.H., Brownlie, S., Martel, P., Garcin, J.P., Hagen, A., Amberger, C., Martin, M., Labadie, F., Collet, M., Drouard, C., Lombard, C., Hervé, D., Strehlau, G. (1999). The effect of benazepril on survival times and clinical signs of dogs with congestive heart failure: Results of a multicenter, prospective, randomized, double-blinded, placebo-controlled, long-term clinical trial. Journal of Veterinary Cardiology. 1(1): 7-18.
- Bruce, W.K. (2015). Cor Triatriatum. Veterinary Image guided Interventions. Editors: Chick Weisse and Allyson Bernt. pp. 127-139.
- Caivano, D., Dickson, D., Martin, M. and Rishniw, M. (2018). Murmur intensity in adult dogs with pulmonic and subaortic stenosis reflects disease severity. Journal of Small Animal Practice. 59: 161-166.
- Castagna, P., Romito, G. and Toaldo, M.B. (2019). Cor triatriatum sinister in a dog. Journal of Veterinary Cardiology. 25: 25-31.
- Church, W.S. (1868). Congenital malformation of the heart: Abnormal septum in the left auricle. Transactions of Pathological Society of London.19: 188-90
- Cote, E., Macdonald, K.A., Meurs, K.M. and Sleeper, M.M.(2011). Congenital malformations, in Feline Cardiology, Wiley- Blackwell, West Sussex, UK, 1st edition. pp. 85-100.
- David, S. (2016). Heart murmurs in puppies and kittens. Companion Animal. 21(7): 376-383.
- Dominique, P. and Marc-Andre d’ A. (2008). Atlas of Small Animal Ultrasonography, I edn., Blackwell Publishing, Australia.
- Garncarz, M., Parzeniecka-Jaworska, M. and Szalus-Jordanow, O. (2017). Congenital heart defects in dogs: A retrospective study of 301 dogs. MedicineWeter. 73: 651-567.
- Ghirlanda, S., Acerbi, A. and Herzog, H. (2014). Dog movie stars and dog breed popularity: A case study in media influence on choice. Pub Lib Sci (PLOS) One. 9: 1-5
- Gordon, B., Trautveter, E. and Patterson, D.F. (1982). Pulmonary congestion associated with cortriatriatum in a cat. Journal of American Veterinary Medical Association. 180(1): 75-77.
- Gustavo, L.G.A., Marcelo, B.A., Carolina, M.S., Angela, V.M., Ludmila, S.C.O. (2012). Cor Triatriatum Sinister in a French Bulldog. Veterinary Medicine. doi:10.1155/2012/413020.
- Hamdan, R., Mirochnik, N., Celermajer, D., Nassar, P. and Iserin, L. (2010). Cor triatriatum sinister diagnosed in adult life with three dimensional transesophageal echocardiography. BMC Cardiac Diseases. 12: 54-60
- Kelmendi, M., Bejiqi, R., Bajraktari, G. and Beqiraj, R.(2009). Cor triatriatum sinister-three case reports. Medical Arhiv. 63(5): 300-302.
- Kittleson, M.D. (1998). Other Congenital Cardiovascular Abnormalities, in Small Animal Cardiovascular Medicine, [Kittleson, M.D. and Kienle, R.D., (Eds)]., Mosby, St. Louis, Mo, USA, 1st edition. pp. 282-296.
- Lima, R.P., Fonseca, C., Sampaio, F., Ribeiro, J. and Ribeiro, V.G. (2010). Cor triatriatum sinistrum-description and review of four cases. Revista Portuguesa de Cardiologia. 29(5): 827-836.
- Macdonald, K.A.(2006). Congenital heart diseases of puppies and kittens. Veterinary Clinics North America. 36(3): 503-531.
- Menaut, P., Fuentes, V.L. and Dennis, S. (2009). Cor Triatriatum Sinister in cats: 5 cases. in 15th FECAVA Eurocongress, AFVAC-SAVAB-LAK, Lille, France, November. pp. 27-29.
- Mitten, R.W., Edwards, G.A. and Rishniw, M. (2001). Diagnosis and management of cortriatriatum dexter in a Pyrenean Mountain dog and an Akita Inu. Australian Veterinary Journal. 79(3): 177-80.
- Nassar, P.N. and Hamdan, R.H. (2011). Cor triatriatum sinistrum: Classification and imaging modalities. Europian Journal of Cardiac Medicine. 1(3): 84-87.
- Oliveira, P., Domenech, O., Silva, J., Vannini, S., Bussadori, R. and Bussadori, C. (2011). Retrospective review of congenital heart disease in 976 dogs. Journal of Veterinary Internal Medicine. 25(3): 477-483.
- Sandra, P.T. (2020). Miscellaneous Congenital Cardiac Abnormalities in Animals. https://www.msdvetmanual.com.
- Thakrar, A., Shapiro, M.D., Jassal, D.S., Neilan, T.G. and King, M.E.E. (2007). Cor triatriatum: the utility of cardiovascular imaging. Canadian Journal of Cardiology. 23(2): 143-145.
- Thomas, P.W., Gaber, C.E., Jacobs, G.J., Kaplan, P.M. and Lombard, C.W. (1994). Recommendations for standards in transthoracic two-dimensional echocardiography in the dog and cat. Veterinary Radiology and Ultrasound. 35: 173-178.
- Tobias, A.H., Thomas, W.P., Kittleson, M.D. and Komtebedde, J. (1993). Cor triatriatum dexter in two dogs. Journal of American Veterinary Medical Association. 202(2): 285-90.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.