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Vol. 24, No. 4 April 2002 Comments? Questions? Email: compendium@medimedia.com Web: VetLearn.com Fax: 800-556-3288

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Article #4 (1.5 contact hours)

Refereed Peer Review

Role of Survey Radiography in Diagnosing Canine Cardiac Disease

KEY FACTS
University of London I Radiographic signs of cardiac disease vary according to the prevailing pathophysiology. I Measuring the cardiac silhouette does not usually aid the diagnosis of cardiac disease. I Survey radiography is useful for diagnosing congestive cardiac failure.

Christopher R. Lamb, MA, VetMB, MRCVS, DACVR, DECVDI Adrian Boswood, MA, VetMB, MRCVS, DVC, DECVIM-CA (Cardiology)
ABSTRACT: Radiography is useful for diagnosing congestive cardiac failure because it enables detection of pulmonary edema, a major sign of left-sided cardiac failure. In dogs that are not in cardiac failure, survey radiography is used routinely to assess cardiac size and shape; however, radiographic measurements of cardiac size are of limited use in diagnosing cardiac disease and subjective assessments of cardiac shape are inaccurate for detecting specific cardiac chamber enlargement. In dogs with suspected cardiac disease, it is important not to put too much emphasis on the radiographic appearance of the cardiac silhouette.

ardiac diseases can impose different loads on the heart depending on their pathophysiology, and the effect on the myocardium is variable depending on the load.1,2 Diseases that impose a volume load, such as mitral insufficiency, result in eccentric hypertrophy or dilation of cardiac chambers with a corresponding increase in the external dimensions of the heart. However, diseases that impose a pressure load, such as aortic stenosis, tend to result in concentric hypertrophy (i.e., thickening of the myocardium that encroaches on the ventricular lumen with little or no change in the external dimensions). Thus the type of cardiac disease that is present will determine what radiographic signs will develop (Figure 1). Structural changes affecting the heart may occur gradually, sometimes over a period of years, and the rate of development of a cardiac lesion also influences the radiographic signs. For example, the most marked left atrial enlargement occurs in dogs with chronic mitral valve disease in which the left atrial wall and surrounding pericardium gradually stretch in response to a chronic moderate increase in left atrial pressure and left ventricular end-diastolic pressure. Animals with acute mitral insufficiency (e.g., as a result of ruptured chorda tendineae) can have a sudden marked increase in left atrial pressure and develop severe pulmonary edema before significant left atrial enlargement has occurred.

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Diagnosing Canine Cardiac Disease 317

Types of Cardiac Enlargement

Concentric hypertrophy Normal Eccentric hypertrophy

Dilation

Figure 1Types of cardiac chamber enlargement that may

Figure 2ANormal radiograph

occur in response to different loads imposed on the heart. Concentric hypertrophy is a likely response to increased afterload (e.g., affecting the left ventricle as a result of aortic stenosis). Eccentric hypertrophy is a likely response to increased preload (e.g., affecting the left ventricle as a result of patent ductus arteriosus or mitral insufficiency). Dilation is a likely response to chronically increased preload and is associated with cardiac failure.

ASSESSMENT OF CARDIAC SIZE In animals that are not in cardiac failure, such as those with a murmur identified during routine physical examination before vaccination, radiographic examination of the heart is focused on evaluating cardiac size and shape. Cardiac size is usually assessed by comparing the appearance of the cardiac silhouette in a patient with examples of normal ones retained in the veterinarians memory; however, veterinarians (including specialists) making such a subjective assessment often experience difficulty deciding whether the cardiac silhouette is enlarged or misshapen.3,4 For example, there is a tendency to falsely assume there is cardiomegaly when examining puppies, brachycephalic breeds, or obese dogs because these dogs usually have a relatively broad, rounded cardiac silhouette. When evaluating the heart, it may be better to compare the patient's radiographs with those of a normal dog of the same breed5; however, the search for suitable comparative radiographs can be time-consuming and inconvenient. Objective methods for evaluating the cardiac silhouette involve measuring various cardiac dimensions and cardiothoracic ratios 6; however, these methods are undermined by the marked interbreed and individual variations in thoracic conformation in dogs (Figure 2) as well as variations in the appearance of the heart resulting from inconsistent positioning for

Figure 2BSmall cardiac silhouette Figure 2Example of difficulty in interpreting the size of the cardiac silhouette. Knowing the breed of dog often aids interpretation of cardiac size and shape; however, this assessment may be difficult if the breed is uncommon (these are radiographs of a Pharaoh hound). (A) Normal radiograph. (B) Radiograph in the same dog showing a small cardiac silhouette (and pulmonary vessels and caudal vena cava) that occurred as a result of hypovolemia following acute hemorrhage. (Note that an optimal diagnostic workup requires a ventrodorsal or dorsoventral radiograph in addition to a lateral radiograph, and interpretation should be based on both. In these and other figures, orthogonal radiographs have been omitted to save space.)

radiography, phase of the respiratory or cardiac cycle, and any other concurrent thoracic diseases.3,4,7 Similarly, a rule of thumb such as "a normal cardiac silhouette in the dog...usually ranges from 2.5 to 3.5 times the width of intercostal spaces"8 is ineffective because it is too crude to be sensitive and makes no allowance for these variations.

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Figure 3Method for determining the VHS measurement on a lateral thoracic radiograph. The long axis measurement of the cardiac silhouette (A) encompasses 5.1 thoracic vertebrae; the short axis measurement (B) encompasses 4.4 vertebrae. Therefore, the VHS = 5.1 + 4.4 = 9.5. The generic normal VHS range is 8.7 to 10.7; therefore, this result is compatible with normal cardiac size.

Figure 4AInspiration

The vertebral heart scale (VHS) is a method of cardiac measurement that compares the dimensions of the cardiac silhouette with the length of thoracic vertebral bodies 9 (Figure 3). Based on analysis of 100 dogs of various breeds, the generic normal range is 8.7 to 10.7. VHS measurements tend to increase in dogs with cardiac disease.10,11 There is a fair correlation between VHS measurements and a variety of other indices of cardiac chamber enlargement, including end-systolic and end-diastolic ventricular diameters as well as duration of the P wave and QRS complex.11 Measuring the cardiac silhouette might be expected to aid radiographic diagnosis of canine cardiac disease; however, this does not appear to be the case. For example, in a recent study, observers ability to correctly identify dogs with cardiac disease did not improve when using the VHS method compared with subjective radiographic interpretation alone.10 When observers changed their initial impression on the basis of a VHS measurement, it was just as likely to result in an incorrect diagnosis as a correct diagnosis.10 Measuring the cardiac silhouette does not aid diagnosis of cardiac disease because there is considerable overlap in results from dogs with cardiac disease and normal dogs (Figure 4). This overlap occurs partly because dogs with concentric hypertrophy and those examined in the early stages of their disease may not have any significant cardiac enlargement and partly because certain breeds have relatively large-appearing hearts. Normal boxers have significantly higher mean VHS measurements than normal dogs of other breeds, and Labrador retrievers have significantly higher mean VHS measurements than other breeds except the

Figure 4BExpiration Figure 4Example of difficulty in interpreting the size of the

cardiac silhouette. Dogs frequently have a larger cardiac silhouette in expiratory radiographs. This is a real difference, not an optical illusion arising because the lung looks relatively smaller. In these lateral radiographs of a golden retriever, the VHS measurement is 10.6 on inspiration (A) and 11.1 on expiration (B). Using a generic normal VHS range of 8.7 to 10.7 and the expiratory radiograph alone would support an erroneous conclusion that this dog has cardiomegaly. (This dog had no clinical signs of cardiac disease; it was radiographed to look for signs of pulmonary metastasis.)

boxer and the cavalier King Charles spaniel12 (Table 1). There is also evidence that females have smaller mean VHS measurements than males.12 Clearly, interbreed differences, and possibly gender, should be taken into account when interpreting the significance of a cardiac measurement. Even when using breed-specific normal VHS ranges, there is still significant overlap between normal dogs and dogs with cardiac disease.12 At the optimal VHS value for separation of cardiac from noncardiac diseased dogs of each breed, the accuracy is relatively low (range, 58% to 83%; Table 1). VHS measurement is an inaccurate method for diagnosing

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Table 1. VHS Measurements on Lateral Thoracic Radiographs of Six Canine Breeds12,a Breed Boxer (n = 33) Labrador retriever (n = 45) German shepherd (n = 39) Doberman pinscher (n = 32) Cavalier King Charles spaniel (n = 27) Yorkshire terrier (n = 29)
a Normal bm Ranges

Normal Range 10.312.6b,c,d,e,f 9.711.7b,g,h,i,j 8.711.2c,g,k 9.010.8d,h,l 9.911.7e,i,k,l,m 9.010.5f,j,m

VHS Cutoff 11.6 10.9 10.2 10.5 11.1 10.4

Accuracy at Cutoff 58% 66% 75% 68% 79% 83%

ranges encompass the 5th to 95th percentiles. with the same superscript are significantly different; P < .03).

cardiac disease in boxers because of their high incidence of aortic stenosis, which tends to result in concentric hypertrophy of the left ventricle with no visible increase in the external cardiac dimension until the condition is advanced. VHS measurement is more accurate for cardiac diagnosis in small breeds of dogs that are affected frequently by mitral insufficiency, which is more likely to be recognized radiographically because it leads to eccentric hypertrophy or cardiac dilation, both of which increase the external cardiac dimensions.12

ASSESSMENT OF CARDIAC SHAPE Veterinarians usually reach their conclusions about the shape of the cardiac silhouette based on a subjective assessment, just as described for assessment of cardiac size. There is limited potential for use of measurements when assessing cardiac shape, although attempts have been made to distinguish left- and right-sided chamber enlargement using measurements.6 Each of the cardiac chambers and great vessels contributes to the cardiac silhouette (Figure 5), thus enlargement of one or more of these structures may change the shape of the cardiac silhouette, sometimes being visible as a localized bulge. For example, left atrial dilation frequently results in a bulge in the cardiac silhouette that is visible on both lateral and dorsoventral radiographs (Figure 6). However, in dogs with right or left ventricular enlargement, there is only fair agreement between the degree of chamber enlargement as assessed subjectively by radiography and measurements made by echocardiography. 13,14 This lack of agreement reflects inaccuracy in radiographic interpretation that occurs because of various factors3,4,7,15:

Figure 5ACardiac silhouette (right recumbent view)

Figure 5BCardiac silhouette (left recumbent view) Figure 5Example of difficulty in interpreting the shape of the cardiac silhouette. Right (A) and left (B) recumbent lateral radiographs of a healthy English springer spaniel in which there is a marked difference in the shape of the cardiac silhouette. In the left lateral view, the heart appears more rounded, which could be misinterpreted as a sign of cardiac dilation or pericardial effusion.

Individual and interbreed variations in cardiac conformation

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Diagnosing Canine Cardiac Disease 321

to avoid biasing their interpretations.24 Under these conditions, the observers reached the correct diagnosis in less than 40% of cases.24 This poor result reflects the difficulty observers had identifying shape changes that can occur in radiographs of dogs with enlarged cardiac chambers (Figure 8). Radiographic signs of specific cardiac chamber enlargement (or pulmonary vascular abnormalities) were recognized by both observers in only 20% of the instances in which they might be expected.24 Abnormal cardiac shape was recognized more frequently in dogs with anomalies that volume-loaded the heart than in dogs with Lateral Dorsoventral anomalies that induced a pressure load on a Figure 6Drawings (based on cardiac angiograms) showing normal anatomy of cardiac chamber,24 again emphasizing the the cardiac chambers as seen on lateral (left) and dorsoventral (right) thoracic influence of pathophysiology on the radiradiographs. The cardiac silhouette has a smooth outline; there are no bulges or ographic appearance of the heart.
depressions. Note the degree of overlap of the right (RV) and left (LV) ventricles when viewed from the lateral aspect and that the right atrium (RA) is almost completely superimposed by other structures on each view. Compared with a clock face, the positions of the aortic arch, pulmonary artery (PA), and left atrial (LA) appendage on the dorsoventral view may be described as 1, 2, and 3 oclock, respectively. (Ao = aorta; RAA = right atrial appendage; CdVC = caudal vena cava; CrVC = cranial vena cava)

Variations in positioning for radiography (Figure 7) Phase of the respiratory and cardiac cycles Lack of change in external cardiac dimensions as a result of concentric thickening of the myocardium Tendency of the pericardium to smooth over any bulge on the surface of the heart

As a result, it is unlikely that radiographic attempts to identify enlargement of these cardiac chambers are reliable. Despite these limitations, many textbooks and articles on the subject of canine congenital cardiac anomalies describe their radiographic features with little emphasis on the difficulties of assessment. Retrospective studies have described abnormal cardiac shape as a sign of enlarged cardiac chambers or great vessels in the majority of dogs with various congenital anomalies,1621 suggesting that it should be possible to diagnose many congenital cardiac anomalies by survey radiography. An exception to this appears to be aortic stenosis, in which the majority of affected dogs have no abnormalities on survey radiographs.22,23 In a recent study, two experienced observers examined the radiographs of 57 dogs with common congenital cardiac anomalies without access to any clinical information

RADIOGRAPHIC SIGNS OF CARDIAC FAILURE Cardiac failure may be divided into forward and backward (congestive) failure.2 Forward cardiac failure may be defined as insufficient cardiac output to maintain normal physiologic functions, including ambulation and perfusion of vital organs (e.g., brain, kidneys). Diagnosis of forward failure is not based on radiography. Backward (congestive) cardiac failure may be defined as increased end-diastolic filling pressure, which leads to congestion of the pulmonary and systemic veins and ultimately results in pulmonary edema and ascites. Cardiac failure may be diagnosed based on physical examination findings or increased plasma levels of atrial natriuretic peptide,25 but thoracic radiography is the most widely used diagnostic method for leftsided congestive heart failure because it enables noninvasive assessment of the pulmonary veins and may be used to distinguish pulmonary edema from other conditions that can cause similar clinical signs, such as bronchopneumonia.3,4 In each pulmonary lobe, the lobar arteries and veins are normally equal in diameter and slightly smaller than their accompanying bronchus in an inspiratory radiograph. In a lateral radiograph, pulmonary veins are ventral to their corresponding lobar artery; in dorsoventral or ventrodorsal radiographs, pulmonary veins are medial to the corresponding lobar artery. Pulmonary congestion may be recognized radiographically when the pulmonary veins appear larger than either the corresponding lobar artery or the bronchus (Figure 9). In any particular

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Lateral

Dorsoventral

Figure 7ACardiac border changes with LA enlargement

Figure 7BMarked LA enlargement (lateral view)

Figure 7CMarked LA enlargement (dorsoventral view)

Figure 7Example of specific cardiac chamber enlargement resulting in a recognizable bulge in the cardiac silhouette.

(A) Drawings showing a change in the shape of the caudal cardiac border on a lateral view (small arrow) and a shallow bulge at the 3 oclock position on the dorsoventral view (large arrow). There is also dorsal displacement of the trachea and the left caudal lobar bronchus on the lateral view (open arrow). This combination of signs is typical of left atrial (LA) enlargement. Lateral (B) and dorsoventral (C) thoracic radiographs of a dog with marked LA enlargement in which similar signs may be observed.

thoracic radiograph, there may be few points at which the lobar vessels can be visualized clearly enough for comparison or measurements. When examining animals with suspected cardiac disease, the dorsoventral radiograph may be preferred to the ventrodorsal because it usually provides a clearer view of the caudal lobar vessels.15 Alternatively, the left lateral recumbent radiograph usually provides a good view of the right cranial lobar vessels.26 The right cranial lobar vessels are normally thinner than the thinnest part of the right fourth rib, and it has been suggested that measurement of these structures aids recognition of pulmonary congestion. 26 In some animals with pulmonary congestion, pulmonary vessels appear to be more numerous than normal, which probably reflects enlargement of vessels that are normally too small to be clearly visualized. Pulmonary edema develops in stages.2729 Initially, edema fluid leaks into the loose tissue around pulmonary vessels and bronchi, and its radiographic

appearance may mimic bronchial wall thickening. There is a tendency for edema to collect first at the hilum, although this may be difficult to recognize radiographically because the hilar region may already have an increased opacity as a result of superimposition of enlarged vessels and the left atrium. Edema fluid then accumulates in the alveolar septa, which become thicker, producing a hazy, diffuse interstitial pattern. Finally, fluid leaks through the epithelium of the alveolar ducts and floods the alveoli. If sufficient alveoli are flooded, the lung appears consolidated (sometimes with air bronchograms) and therefore is classified radiographically as an alveolar pattern (Figure 10). In dogs, pulmonary edema is usually most marked radiographically in the caudal lobes but may affect the entire lung in individuals with severe cases. Pulmonary edema tends to obscure the heart and pulmonary vessels, making their evaluation more difficult. Note that if an animal with cardiac failure becomes

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Figure 8APulmonic stenosis in a German shepherd Figure 8Example of difficulty in correctly recognizing signs of congenital cardiac anomalies in dogs. (A) Dorsoventral view of a young German shepherd with pulmonic stenosis. There is radiographic evidence of an enlarged pulmonary artery (large arrow) and enlarged right ventricle (small arrows). (B) Dorsoventral view of a young schnauzer with pulmonic stenosis. There is no radiographic sign of pulmonary artery enlargement. The position of the cardiac apex well to the left of midline suggests possible enlargement of the right ventricle; however, this appearance could also reflect an expiratory exposure, thus there is little radiographic evidence to suggest the diagnosis. (C) Dorsoventral view of a young weimaraner with a systolic murmur. There is a focal bulge at the 2 oclock position compatible with an enlarged pulmonary artery, and there is a sharply curved right cardiac border, possibly suggesting an enlarged right ventricle. This combination of signs is compatible with pulmonic stenosis; however, a comprehensive Doppler echocardiographic examination found mild aortic stenosis (and no sign of pulmonic stenosis or right ventricular enlargement or hypertrophy). The radiographic appearance reflects a normal variant. (Figure 8C is reproduced from Lamb CR, Boswood A, Volkman A, Connolly D: Assessment of survey radiography as a method for diagnosis of congenital cardiac diseases in dogs. J Small Anim Pract 42:541545, 2001; with permission.)

Figure 8BPulmonic stenosis in a schnauzer

Figure 8CAortic stenosis in a weimaraner

hypovolemic (e.g., because of concurrent disease), the reduction in circulating blood volume may mask signs of cardiac enlargement and pulmonary congestion and its radiographs may appear normal. In such a case, rehydration may result in rapid development of pulmonary congestion and edema.

Radiographic signs that may be observed in dogs with right-sided cardiac failure include an enlarged caudal vena cava, hepatomegaly, and pleural and/or peritoneal fluid. It is generally accepted that radiography is more sensitive for detecting peritoneal fluid than physical examination, but peritoneal fluid may occur for a

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Pulmonary Vascular Anatomy

A B V

A B V

Normal

Congested

Figure 10APulmonary edema (lateral view) Figure 9APulmonary vein enlargement

Bronchus Vein

Figure 9BLeft cranial lobar vein enlargement Figure 9Radiographic signs of pulmonary congestion. (A)

Enlargement of pulmonary veins, which may be recognized by comparing veins (V) with arteries (A) in radiographs that show them either side-on (top) or end-on (bottom; B = bronchus). In lateral radiographs, pulmonary veins are ventral to their corresponding lobar artery; in dorsoventral or ventrodorsal radiographs, pulmonary veins are medial to the corresponding lobar artery. (B) Detail of a lateral thoracic radiograph in which enlargement of the left cranial lobar vein is visible just ventral to the bronchus in a dog with mitral stenosis.

Figure 10BPulmonary edema (dorsoventral view) Figure 10Lateral (A) and dorsoventral (B) thoracic radi-

ographs of a dog with marked pulmonary edema, which is visible as an alveolar infiltrate that is most marked in the caudal lobes. Dorsal displacement of the trachea on the lateral view suggests cardiac enlargement; however, the pulmonary infiltrate obscures the caudal cardiac border, hindering assessment of cardiac size and chamber bulges.

variety of reasons; therefore, it is not a specific sign of congestive cardiac failure.

CONCLUSIONS Survey radiography is used routinely as part of the diagnostic workup in animals with suspected cardiac disease; however, clinicians should be cautious when interpreting radiographs, particularly in dogs that are not in cardiac failure, because survey radiography is not an accurate method for assessing cardiac size or

shape. Radiography should be considered only one part of the workup, and an attempt should routinely be made to integrate the clinical and radiographic signs to avoid placing unwarranted emphasis on the perceived size or shape of the cardiac silhouette alone. Survey radiography is a useful method for diagnosing congestive cardiac failure because it enables examination of pulmonary vessels and detection of pulmonary edema, which is a major sign of left-sided

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cardiac failure. Survey radiography also aids differentiation of cardiac failure from various other pulmonary or pleural conditions that may produce similar clinical signs.

18. Fingland RB, Bonagura JD, Myer CW: Pulmonic stenosis in the dog: 29 cases (19751984). JAVMA 189:218226, 1986. 19. Ringwald RJ, Bonagura JD: Tetralogy of Fallot in the dog: Clinical findings in 13 cases. JAAHA 24:3343, 1988. 20. Sisson D, Luethy M, Thomas WP: Ventricular septal defect accompanied by aortic regurgitation in five dogs. JAAHA 27:441448, 1991. 21. Lehmkuhl LB, Ware WA, Bonagura JD: Mitral stenosis in 15 dogs. J Vet Intern Med 8:217, 1994. 22. Levitt L, Fowler JD, Schuh JCL: Aortic stenosis in the dog: A review of 12 cases. JAAHA 25:357362, 1989. 23. OGrady MR, Holmberg DL, Miller CW, Cockshutt JR: Canine congenital aortic stenosis: A review of the literature and commentary. Can Vet J 30:811815, 1989. 24. Lamb CR, Boswood A, Volkman A, Connolly D: Assessment of survey radiography as a method for diagnosis of congenital cardiac diseases in dogs. J Small Anim Pract 42:541545, 2001. 25. Boswood A, Attree S, Page K: Clinical validation of a Pro-ANP 31-67 fragment ELISA in the diagnosis of naturally occurring canine heart failure [abstract]. J Small Anim Pract 42:365, 2001. 26. Thrall DE, Losonsky JM: A method for evaluating canine pulmonary circulatory hemodynamics from survey radiographs. JAAHA 12:457462, 1976. 27. Staub NC, Nagano H, Pearce ML: Pulmonary edema in dogs, especially the sequence of fluid accumulation in lungs. J Appl Physiol 22:227240, 1967. 28. Conhaim RL: Airway level at which edema fluid enters the air space of isolated dog lungs. J Appl Physiol 67:22342242, 1989. 29. Forster BB, Muller NL, Mayo JR, et al: High-resolution computed tomography of experimental hydrostatic pulmonary edema. Chest 101:14341437, 1992.

REFERENCES
1. Hamlin RL: Pathophysiology of the failing heart, in Fox PR, Sisson D, Moise NS (eds): Textbook of Canine and Feline Cardiology. Philadelphia, WB Saunders Co, 1999, pp 205215. 2. Katz AM: Physiology of the Heart, ed 3. Philadelphia, Lippincott, Williams and Wilkins, 2001, pp 658673. 3. Kittleson MD: Radiology, in Kittleson MD, Kienle RD (eds): Small Animal Cardiovascular Medicine. St. Louis, Mosby, 1998, pp 4771. 4. Lord PF, Suter PF: Radiology, in Fox PR, Sisson D, Moise NS (eds): Textbook of Canine and Feline Cardiology. Philadelphia, WB Saunders Co, 1999, pp 107129. 5. Lord PF: Cardiac mensuration, in Kirk RW (ed): Current Veterinary Therapy, ed 5. Philadelphia, WB Saunders Co, 1974, pp 339340. 6. Hamlin RL: Analysis of the cardiac silhouette in dorsoventral radiographs from dogs with heart disease. JAVMA 153: 14461460, 1968. 7. Silverman S, Suter PF: Influence of inspiration and expiration on canine thoracic radiographs. JAVMA 166:502510, 1975. 8. Owens JM, Biery DN: Radiographic Interpretation for the Small Animal Clinician, ed 2. Baltimore, Williams and Wilkins, 1999, pp 185216. 9. Buchanan JW, Bcheler J: Vertebral scale system to measure canine heart size in radiographs. JAVMA 206:194199, 1995. 10. Lamb CR, Tyler M, Boswood A, et al: Assessment of the value of the vertebral heart scale in the radiographic diagnosis of cardiac disease in dogs. Vet Rec 146:687690, 2000. 11. Nakayama H, Nakayama T, Hamlin RL: Correlation of cardiac enlargement as assessed by vertebral heart size and echocardiographic and electrocardiographic findings in dogs with evolving cardiomegaly due to rapid ventricular pacing. J Vet Intern Med 15:217221, 2001. 12. Lamb CR, Wikeley H, Boswood A, Pfeiffer DU: Use of breedspecific ranges for vertebral heart scale in dogs as an aid to radiographic diagnosis of cardiac disease. Vet Rec 148:707711, 2001. 13. Lombard CW, Ackerman N: Right heart enlargement in heartworm-infected dogs: A radiographic, electrocardiographic, and echocardiographic correlation. Vet Radiol 25:210217, 1984. 14. Lombard CW, Spencer CP: Correlation between radiographic, echocardiographic, and electrocardiographic signs of left heart enlargement in dogs with mitral regurgitation. Vet Radiol 26:8997, 1985. 15. Ruehl WW, Thrall DE: The effect of dorsal versus ventral recumbency on the radiographic appearance of the canine thorax. Vet Radiol 22:1016, 1981. 16. Suter PF, Lord PF: A critical evaluation of the radiographic findings in canine cardiovascular diseases. JAVMA 158:358371, 1970. 17. Ackerman N, Burk R, Hahn AW, Hayes HM: Patent ductus arteriosus in the dog: A retrospective study of radiographic, epidemiologic, and clinical findings. Am J Vet Res 39:18051810, 1978.

ARTICLE #4 CE TEST The article you have read qualifies for 1.5 contact hours of Continuing Education Credit from the Auburn University College of Veterinary Medicine. Choose the best answer to each of the following questions; then mark your answers on the postage-paid envelope inserted in Compendium.

CE

1. Which of the following morphologic changes is least likely to be visible radiographically as an increase in size of the cardiac silhouette? a. concentric hypertrophy b. eccentric hypertrophy c. dilation d. pericardial effusion 2. Which of the following factors may influence the appearance of the cardiac silhouette? a. left versus right recumbency b. phase of respiration c. breed of dog d. all of the above
(continues on page 352)

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Canine Cardiac Disease (continued from page 326)

3. Which of the following canine breeds has the highest normal VHS range? a. boxer b. Labrador retriever c. German shepherd d. cavalier King Charles spaniel 4. What is the generic normal VHS range? a. 8.2 to 10.2 b. 8.5 to 10.5 c. 8.7 to 10.7 d. 8.9 to 10.9 5. What cardiac structure normally occupies the 2 oclock position on the cardiac silhouette on a dorsoventral radiograph? a. aortic arch b. pulmonary artery c. left atrial appendage d. right atrial appendage 6. Which of the following congenital cardiac anomalies is least likely to result in abnormal cardiac size or shape? a. pulmonic stenosis b. aortic stenosis c. patent ductus arteriosus d. mitral stenosis 7. Survey radiographic signs in dogs with congenital cardiac anomalies are a. seen most frequently in dogs with pressure-loading anomalies such as aortic or pulmonic stenosis. b. seen most frequently in dogs with volume-loading anomalies such as patent ductus arteriosus. c. present in the majority of dogs. d. the basis for prognosis. 8. Which of the following statements about radiographic signs of pulmonary congestion is correct? a. The right lateral recumbent radiograph is preferred for assessing the right cranial lobar vessels. b. The left lateral recumbent radiograph is preferred for assessing the right cranial lobar vessels. c. The thickness of congested veins usually exceeds the thickness of the ribs. d. Diagnosis of congestion depends on precise measurements of affected vessels. 9. The usual radiographic sequence showing development of pulmonary edema in dogs with congestive cardiac failure is a. alveolar, interstitial, hilar. b. hilar, alveolar. c. peribronchial, interstitial, alveolar. d. interstitial, peribronchial, alveolar. 10. Which of the following statements regarding the use of survey radiography for diagnosing cardiac disease is correct? a. Radiographic signs of cardiac disease are unrelated to the prevailing pathophysiology. b. Quantitative assessment of the cardiac silhouette is the key to optimal diagnostic accuracy. c. Survey radiography is an accurate method for identifying cardiac chamber enlargement. d. Survey radiography is useful for diagnosing cardiac failure.