Diagnostic Imaging Measurements

in Dogs with Myxomatous Mitral

Valve Disease (MMVD)
The American College of Veterinary Internal Medicine (ACVIM) produced consensus guidelines for the diagnosis and
treatment of dogs with MMVD1. A staging system is used for dogs with MMVD:
Dogs with structural heart disease (e.g. presence of MMVD) but who have never had clinical signs of heart failure

A B1 B2 C D
Dogs at risk Asymptomatic dogs Asymptomatic dogs Clinical Dogs with clinical
• No identifiable • No radiographic or echocardiographic evidence of cardiac • Where there are radiographic and echocardiographic findings of signs of signs of heart
structural disorder remodelling, or those in which remodelling changes are left atrial and ventricular enlargement that meet clinical trial criteria heart failure which
(e.g. All King Charles present but not severe enough to meet criteria that have used to identify dogs that clearly should benefit from initiating failure are refractory to
Cavalier Spaniels) been used to determine that initiating treatment is warranted pharmacologic treatment to delay the onset of heart failure standard treatment

The consensus guidelines set out the criteria for staging dogs as B2

Echocardiographic LA:Ao
1 Left ventricular internal
2 General breed
3 Vertebral left
4 Murmur
5
ratio in the right-sided short diameter in diastole, normalized vertebral heart atrial size (VLAS) intensity grade
axis view in early diastole ≥1.6 for body weight (LVIDDN) ≥1.7 score (VHS) ≥11.5* values of ≥3* 3/6 or louder
*Useful as an adjunct to/in the absence of echocardiography

1 2
Echocardiographic LA:Ao ratio Left ventricular internal diameter in diastole, normalized for body weight (LVIDDN) 3

in the right-sided short axis • Using a right parasternal short axis view at the level
A B of the papillary muscles (“Mushroom view”, Image
view in early diastole2 A), an M-mode trace is acquired (Image B)
• End diastolic measurements are acquired at the
start of the QRS complex on the ECG
• Measure leading-edge to leading-edge
• Take multiple measurements and try to be consistent
in taking the measurement at the same point in the
cardiac cycle using the same anatomical landmarks
• Normalisation to weight can be obtained using the
formula:
LVIDDN = Left Ventricular Internal Diameter in
Diastole (cm)/Bodyweight (kg)0.294

LVIDDN ≥1.7 indicates left ventricular

enlargement

• Measured in early diastole – the first frame where 3

the aortic valve is closed Vertebral heart score (VHS) 4
• Aorta (Ao): measure the transverse diameter • Measured using a lateral thoracic • The vertebral heart score is the sum of
of the aorta using a straight line from the mid- projection both lines measured in vertebral body
point of the right aortic wall to the junction units to the nearest 0.1 of a vertebra
• Measure the long axis of the cardiac
of the non-coronary and left coronary valve
silhouette from the ventral border of the
cusps at the left aortic wall (1) A general breed VHS of ≥11.5
carina to the cardiac apex (1)
• Left atrium (LA): measure the transverse
diameter of the left atrium by extending the
• Measure the short axis of the cardiac indicates the presence of
straight line used to measure the aorta, starting
silhouette at the widest point cardiomegaly. However, breed
perpendicular to the long axis line (2)
from the blood-tissue interface of the medial
• Draw lines equal in length to (1) and
variation exists5 and, where breed
left atrial wall to the blood tissue interface of
the lateral aortic wall (2). Where the junction of (2) beginning at the cranial border of specific VHS normal values are
the pulmonary vein prevents visualisation of the the 4th thoracic vertebra (T4) extending available, a breed adjusted VHS
lateral left atrial wall then the calliper can be parallel to the vertebral canal
of >10.5 can be used
placed at an extrapolation of the atrial border
• Take multiple measurements and try to be
consistent in taking the measurement at the
same point in the cardiac cycle using the same
anatomical landmarks 4
LA:Ao ratio of ≥ 1.6 indicates left atrial
Vertebral Left Atrial Size (VLAS) 6

enlargement
• Measured using a lateral thoracic VLAS values of ≥3 likely identify
projection
Stage B2 MMVD1
• Draw a line from the centre of the ventral
References aspect of the carina (the radiolucent Recent research papers support values of >2.3
1. Keene B.W., Atkins C.E., Bonagura J.D., Fox P.R., Häggström J., Luis Fuentes V., oval/circular structure within the - 2.5 identifying dogs with hemodynamically
Oyama M.A., Rush J.E. Stepien R., Uechi M. (2019) ACVIM consensus guidelines for trachea representing the bifurcation important MMVD6,7
the diagnosis and treatment of myxomatous mitral valve disease in dogs. Journal of
Veterinary Internal Medicine 33: 1127-1140 of the mainstem bronchi) to the most
2. Hansson K., Häggström J., Kvart C., Lord P. (2002) Left atrial root indices using two- caudal aspect of the left atrium where
dimensional and M-mode echocardiography in cavalier king charles spaniels with
and without left atrial enlargement. Veterinary Radiology and Ultrasound 43: 568-575 it intersects with the dorsal border of the
3. Cornell C.C., Kittleson M.D., Della Torre P., Häggström J., Lombard C.W., Pedersen H.D, caudal vena cava (1)
Vollmar A., Wey A. (2004) Allometric scaling of M-mode cardiac measurements in
normal adult dogs. Journal of veterinary Internal Medicine 18 311-321 • Draw a second line that is equal in length
4. Buchanan J.W., Bücheler J. (1995) Vertebral scale system to measure canine heart size to the first at the beginning of the cranial
in radiographs. Journal of the American Veterinary Medical Association 206: 194-199
5. Lamb C.R., Wikeley H., Boswood A., Pfeiffer D.U., (2001) Use of breed-specific ranges edge of T4 and extending caudally just
for the vertebral heart scale as an aid to the radiographic diagnosis of cardiac ventral and parallel to the vertebral
disease in dogs. The Veterinary Record 148: 707-711
6. Malcolm E.L., Visser L.C., Philips K.L., Johnson L.R. (2018) Diagnostic value of vertebral
canal (2)
left atrial size as determined from thoracic radiographs for assessment of left atrial size
in dogs with myxomatous mitral valve disease. Journal of the American Veterinary
• The VLAS is defined as the length of the
Medical Association 253: 1038 -1045 second line expressed in vertebral body
7. Stepien R.L., Rak M.B., Blume L. M. (2020) Use of radiographic measurements to units to the nearest 0.1 vertebra
diagnose stage B2 preclinical myxomatous mitral valve disease in dogs. Journal of the
American Veterinary Medical Association 256: 1129 - 1136

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