Received: 31 January 2020 Revised: 25 April 2020 Accepted: 27 April 2020

DOI: 10.1111/vru.12896

O R I G I N A L I N V E S T I G AT I O N

Radiographic vertebral left atrial size: A reference interval

study in healthy adult dogs

Tommaso Vezzosi Caterina Puccinelli Rosalba Tognetti Tina Pelligra

Simonetta Citi

Department of Veterinary Sciences, University

of Pisa, Pisa, Italy
Correspondence
Rosalba Tognetti, Department of Veterinary
Sciences, University of Pisa, Via Livornese, San
Piero a Grado, 56010, Pisa, Italy.
Email: rosalba.tognetti@unipi.it
Abstract
Thoracic radiography is a useful technique for the evaluation of cardiac dimensions,
especially when echocardiography is not possible. The vertebral left atrial size (VLAS)
has recently been proposed as a new radiographic method for quantifying left atrial
dimensions in dogs. The aims of this retrospective, reference interval, observational
study were to describe values for VLAS in a group of healthy adult dogs and to com-
pare intraobserver and interobserver agreement for VLAS versus vertebral heart score
(VHS) methods. Thoracic radiographs of 80 healthy adult dogs were evaluated. Nor-
mal left atrial size was determined based on an echocardiographic left atrial-to-aorta
ratio < 1.6. The VLAS and vertebral heart score values were measured from right lat-
eral radiographs. The correlations between VLAS, the vertebral heart score, and the
left atrial-to-aorta ratio were evaluated. The effects of body weight, sex, and age were
also tested using regression analyses. The median value of VLAS were 1.9, with a ref-
erence interval of 1.4-2.2. A positive correlation was found between VLAS and verte-
bral heart score values (r = 0.53; P < .0001). No effect of body weight, sex, and age on
VLAS was detected. Excellent intraobserver and interobserver agreements were found
for both VLAS and vertebral heart score methods (intraclass correlation coefficients ≥
0.91). Findings from this sample of healthy dogs indicated that VLAS is a repeatable
radiographic method for quantifying left atrial size. Further studies are warranted to
evaluate this measure in clinically affected dogs.

KEYWORDS
cardiac dimension, cardiology, radiography, reference range, VLAS

1 INTRODUCTION
Thoracic radiography is a key component for the study of the car-
diovascular system.1 Radiographic diagnosis of cardiac disease is
Abbreviations: ICC, intraclass correlation coefficient; LA, left atrium; LA/Ao, left
atrium-to-aorta ratio; VLAS, vertebral left atrial size.
Previous presentation or publication disclosure: The results of the present study had not pre-
viously been presented at any scientific meeting and/or published in an abstract.
EQUATOR network disclosure: No EQUATOR network checklist was used.
based on the evaluation of the size and shape of the cardiac silhou-
ette, pulmonary vessels, and signs of congestive heart failure. Most
radiographic assessments of cardiovascular structures are performed
subjectively.2 However, quantitative methods to evaluate cardiac
dimensions have been developed. The vertebral heart score (VHS)
is the most commonly used method for the objective evaluation of
cardiac size in thoracic radiographs in dogs.3 Differences in VHS
according to the canine breed have also been described.4-11 However,
there are few studies in veterinary medicine aimed at standardizing
the radiographic left atrial (LA) size.12-15

Vet Radiol Ultrasound. 2020;1–5. wileyonlinelibrary.com/journal/vru © 2020 American College of Veterinary Radiology 1
2 VEZZOSI ET AL .

In dogs, myxomatous mitral valve disease is the most common

cardiac disease. Left atrial enlargement is considered a major indi-
cator of mitral regurgitation severity and has been recognized as a
strong predictor of outcome in dogs with myxomatous mitral valve
disease.16 There are numerous echocardiographic methods of mea-
suring LA size, with the most common being the left atrial-to-aorta
ratio (LA/Ao).17 Although transthoracic echocardiography is the non-
invasive, gold standard method to assess LA size, it is not always possi-
ble to perform because of the cost of the examination and the knowl-
edge and equipment required, or because of the critical clinical con-
ditions of some patients. Thoracic radiography is easily available, less
expensive, and faster to perform.
A newer index of radiographic LA size, the vertebral left atrial size
(VLAS), was recently included in the American College of Veterinary
Internal Medicine consensus guidelines for the diagnosis and treat-
ment of myxomatous mitral valve disease.17 One study proposed a cut-
off of VLAS ≥ 2.3 vertebrae as a radiographic indicator of LA enlarge-
ment in dogs, but only 15 normal dogs were included in the study.13 For
the definition of a reference range in the canine population, a larger
sample is desirable. In addition, no previous studies have evaluated F I G U R E 1 Lateral thoracic radiograph illustrating methods used
for measuring vertebral left atrial size in a dog of the study (kVp 61,
the effects of sex, age, and body weight on VLAS. Thus, the aims of
mAs 8.0). A line was measured from the center of the most ventral
our study were to describe a reference interval for VLAS values in a aspect of the carina to the most caudal aspect of the left atrium where
large population of healthy dogs and compare intraobserver and inter- it intersected with the dorsal border of caudal vena cava. The same
observer agreement for VLAS versus VHS methods. We hypothesized line, then, was drawn beginning at the cranial edge of T4 and extending
that body weight, sex, and age would have no effect on VLAS values caudally just ventral and parallel to the vertebral canal, and the length
was expressed in vertebral body units to the nearest 0.1 vertebra. For
(similar to VHS) and that this new radiographic measurement would
this dog, the VLAS was 2.2 vertebrae
have good intra- and interobserver measurement agreement.

2 MATERIALS AND METHODS
This study was a retrospective, reference interval, observational
design. Case inclusion was performed at the Veterinary Teaching Hos-
pital of the Department of Veterinary Sciences, University of Pisa. Due
to the retrospective study design, no institutional animal care and use
approval or client consent was sought. However, all owners had signed
an informed consent based on which they had agreed on the possible
future use of the data acquired during the clinical evaluation of their
pets for teaching or medical research. The Hospital director approved
the use of the clinical data for the present study. Medical records
from between January 2017 and November 2019 were reviewed for
healthy, adult, client-owned dogs. Dogs were defined as healthy based
on history, physical examination, thoracic radiographs, and echocardio-
graphy. All cases had to have undergone an echocardiographic exam-
ination within 24 h before or 7 days after the radiographic examina-
tion. Exclusion criteria consisted of any finding indicating cardiac or
systemic disease. Dogs were also excluded from the study if thoracic
radiography showed malposition of the patient (eg, abnormal position
of the thoracic vertebral column and the trachea) or thoracic vertebral
abnormalities. All decisions for dog inclusion or exclusion were made
by two observers, a third-year veterinary cardiology resident (T.V.) and
an Italian Recognized Specialist in Veterinary Radiology (S.C.), based on
a consensus opinion.
As part of the inclusion criteria for the study, all thoracic radiographs
were acquired using the same high-frequency digital radiography sys-
tem (MAXIVET 400 HF, Multimage s.r.l., Cavaria, Varese, Italy) and
were analysed using the same image analysis workstation (Fuji Com-
puted Radiography Capsula X, FUJIFILM Corporation, Tokyo, Japan).
An Italian Recognized Specialist in Veterinary Radiology with 30 years
of experience in the field (S.C.) reviewed all radiographs and performed
measurements. The operator was blinded to the results of the echocar-
diographic examination at the time of radiographic measurements. For
each dog, the right lateral radiographic view was used for measuring
the VLAS and the VHS, using a free and open source code software
program (Horos, Horosproject.org, Nimble Co LLC d/b/a Purview in
Annapolis, MD, USA). The VLAS was measured as established by Mal-
colm et al.13 A line was measured from the center of the most ventral
aspect of the carina to the most caudal aspect of the left atrium where
it intersected with the dorsal border of the caudal vena cava. The same
line was then repositioned over the thoracic vertebrae, as described
for the VHS, and the length was expressed in vertebral body units to
the nearest 0.1 vertebra (Figure 1). The VHS was measured as previ-
ously described.3 Briefly, the long axis of the heart was measured from
the ventral border of the largest mainstem bronchus to the most dis-
tant ventral contour of the cardiac apex. The short axis was measured
in the central third region of the heart, perpendicular to the long axis,
from the cranial to caudal border of the widest portion of the heart.
Measurements of both long and short axis were then positioned over
VEZZOSI ET AL .
F I G U R E 2 Lateral thoracic radiograph illustrating methods used
for vertebral heart score measurement in a dog of the study (kVp 61,
mAs 8.0). For this dog, the vertebral heart score was 11 vertebrae
thoracic vertebrae, beginning at the cranial edge of the fourth thoracic
vertebra and the number of vertebral units was estimated to the near-
est 0.1 vertebral body length. The sum of the two measurements was
used to calculate the VHS (Figure 2).
To asses intra- and interobserver agreement for VLAS compared to
VHS methods, two additional observers, an Italian Recognized Special-
ist in Veterinary Radiology (S.C.) and a first-year PhD student in vet-
erinary radiology (C.P.), reviewed the right lateral thoracic radiographic
images of 10 randomly selected dogs on three separate occasions, each
of them 7 days apart. The measurements were performed indepen-
dently by the two investigators, both of whom were blinded to the pre-
vious measurements and the order of radiographic studies was ran-
domized (“RANDBETWEEN” function in the Excel software, Microsoft
Office 365, Microsoft Corporation, Redmond, WA, USA).
As part of the inclusion criteria for the study, all echocardiographic
examinations were performed by the same third-year veterinary car-
diology resident (T.V.) on unsedated dogs that were positioned in
right and left lateral recumbency. The same ultrasonographic machine
and phased-array transducers were used (Aplio 300, Canon Medical
Systems Europe, Zoetermeer, Netherlands). Simultaneous ECG trac-
ings were also recorded. Each dog underwent a complete echocardio-
graphic examination, which included transthoracic 2D, M-mode, spec-
tral, and color Doppler imaging.18 The measurement of the LA/Ao was
obtained from the right parasternal short-axis view, at the aortic valve
level, in early diastole (first measurable frame after aortic valve clo-
sure) as shown in Figure 3.19 The correct timing was confirmed using
the ECG trace on the monitor. The LA size was considered normal using
the reported cutoff of LA/Ao < 1.6.19 The operator was blinded to the
results of the thoracic radiographs at the time of echocardiographic
measurements.
3
F I G U R E 3 Echocardiographic image illustrating methods used for
measurement of the left atrium-to-aorta ratio in a dog of the study
(3 MHz phased-array transducer). The image was acquired from the
right parasternal short axis view in early diastole. For this dog, the left
atrium-to-aorta ratio was 1.5 [Color figure can be viewed at
wileyonlinelibrary.com]
Statistical analyses were performed by a veterinarian with course-
work training in statistics, using commercially available statistical
software (GraphPad Prism 5.0, GraphPad Software Inc, San Diego, CA,
USA; IBM SPSS Statistics 21.0; IBM Corporation Armonk, New York,
USA). Descriptive statistics were generated. The normality of data
distribution was tested using the Shapiro-Wilk test. An open-source
application to calculate reference intervals was used (Reference Value
Advisor V2.1).20 The nonparametric method was used to determine
the reference interval of VLAS using the entire eligible data set.
The correlation between VLAS and VHS was obtained by means of
Spearman’s correlation. Multiple linear regression analyses were used
to explore the relationship between VLAS and body weight, age, and
sex. An intraclass correlation coefficient (ICC) was used to quantify
intraobserver and interobserver measurement agreement for VLAS
and VHS. For ICC calculations, a two-way single measures mixed effect
model for absolute agreement was used.21 The agreement of the
investigators performing the measurements was considered poor if
the value was 0-0.2, fair if 0.21-0.40, moderate if 0.41-0.6, substantial
if 0.61-0.8, and almost perfect if 0.81-1.22 Values of P < .05 were
considered statistically significant.
3 RESULTS
The study sample consisted of 80 healthy, client-owned dogs. There
were 37 males and 43 females, with a median age of 7.4 years (range, 1-
17 years) and a median body weight of 11 kg (range, 1.4-55 kg). Twenty-
one dogs weighed < 5 kg, 15 dogs weighed ≥5 to <10 kg, 14 weighed
≥10 to <20 kg, 13 weighed ≥20 to <30 kg, and 17 were ≥30 kg. The
breeds represented in the study were Chihuahua (n = 23), mixed-breed
(n = 17), Golden Retriever (n = 6), Labrador (n = 5), Dachshund (n = 3),
Beagle (n = 2), German Shepherd (n = 2), Miniature Pinscher (n = 2),
4 VEZZOSI ET AL .
F I G U R E 4 Graph illustrating a positive linear correlation between
VLAS and VHS values (r = 0.53; P < .001). VLAS, vertebral left atrial
size; VHS, vertebral heart score
Poodle (n = 2), West Highland White Terrier (n = 2), and one of each
of the following: Belgian Malinois, Bolognese, Border Collie, Boxer,
Cavalier King Charles, Central Asian Shepherd, Cocker Spaniel, Dogo
Argentino, English Setter, Irish Setter, Segugio Italiano, Magyar Vizsla,
Maremma Sheepdog, Spanish Galgo, Spitz, and Yorkshire Terrier.
The median value of VLAS was 1.9 (range, 1.3-2.2), with a reference
interval between 1.4 (90% confidence interval 1.3-1.5) and 2.2 (90%
confidence interval 2.1-2.2). No effect of body weight, sex, and age on
VLAS was detected based on multivariate analysis. The median value of
VHS was 10 (range, 9.2-11). A positive correlation was found between
VLAS and VHS (r = 0.53, P < .0001, Figure 4).
For intraobserver measurement agreement, both VLAS and VHS
methods showed excellent agreement with an ICC of 0.95 (0.82-0.99)
and 0.94 (0.82-0.98), respectively. Similarly, for interobserver mea-
surement agreement, both VLAS and VHS methods showed excel-
lent agreement with an ICC of 0.91 (0.48-0.98) and 0.95 (0.83-0.99),
respectively.
4 DISCUSSION
This study described a reference interval for VLAS values based on a
large sample of healthy adult dogs, and findings supported use of this
new index as a radiographic measure of LA size. One study showed that
subjective assessment of radiographic LA enlargement has only mod-
erate agreement with echocardiographic LA enlargement severity.23
Only a few recent studies have reported a quantitative radiographic
evaluation of LA size in healthy dogs.13-15
Our results showed that the reference interval of VLAS in dogs is
between 1.4 and 2.2. This finding is in line with the preliminary study
of Malcolm et al, in which a VLAS ≥ 2.3 was proposed as a diagnostic
cutoff for LA enlargement.13
In our study, a positive correlation was found between VLAS and
VHS. This result can be explained by the fact that VLAS could be
influenced by breed variations, as already shown for VHS.4 In fact, a
possible factor affecting VLAS in small breeds could be breed-specific
variations in vertebral body length relative to overall body size, as
hypothesized for VHS by a previous study.7
For intraobserver and interobserver measurement agreement,
VLAS and VHS showed an almost perfect agreement. This finding pro-
vides evidence that VLAS and VHS are repeatable methods for measur-
ing cardiac chamber size, as confirmed by previous studies.10,11,13 Fur-
ther studied are needed to verify if veterinarians with different clinical
experience and specialization (eg, general practitioners, cardiologists,
intensive care clinicians) have the same measurement variability.
In our study, the interobserver measurement agreement for VHS
was slightly greater than for VLAS. This could be due to the fact that
VHS is a traditional measurement, and several studies have clarified
how to measure it.3,24 On the other hand, VLAS is a newer radiographic
index. Another possible explanation could be that there is greater vari-
ability among operators in establishing the decimal part of the number
of vertebrae, which could have a greater influence on VLAS measure-
ment than on VHS.
Our results should be considered within the context of the study’s
limitations. First, the possible influence of the body condition score
on VLAS was not evaluated. Previous studies have reported the possi-
ble influence of body condition score on VHS.7,9,11 However, all dogs
included in the study were healthy, and no obese or cachectic dogs
were present in the study population. Second, the study population
included a large variety of dogs of different weights and ages; however,
no brachycephalic “screw-tailed” breeds (eg, English Bulldog, French
Bulldog, Pug, Boston terrier) were included. These breeds present a
typical barrel-shaped thoracic conformation in comparison to other
dogs, and a greater occurrence of thoracic vertebral body anomalies25
that could alter the measurement of vertebral-based methods. The
reference interval for VLAS determined in this study may thus not
be applicable to brachycephalic dogs. Further studies on VLAS mea-
surements in different breeds are recommended. Third, for intraob-
server and interobserver variability, all radiographic measurements
were performed by operators working in radiology. Thus, the measure-
ment variability found in this study may not be superimposable on that
of non-radiology colleagues (eg, general practitioners, cardiologists,
intensive care clinicians, etc). Lastly, the study did not include over-
weight, aggressive, severely panting or dyspneic dogs, nor did it include
low quality thoracic radiographs, therefore it cannot be excluded
that greater measurement variability may occur in such clinical
conditions.
In conclusion, the current study provided a reference interval for
VLAS values in healthy dogs and indicated that measures of VLAS are
repeatable and reliable. Further studies evaluating the diagnostic util-
ity of VLAS in the clinical staging of dogs with myxomatous mitral valve
disease and other cardiac diseases are needed.
LIST OF AUTHOR CONTRIBUTIONS
Category 1
(a) Conception and Design: Vezzosi, Citi, Tognetti
(b) Acquisition of Data: Vezzosi, Puccinelli, Pelligra, Citi
(c) Analysis and Interpretation of Data: Vezzosi, Puccinelli, Citi
VEZZOSI ET AL .
Category 2
(a) Drafting the Article: Vezzosi, Puccinelli
(b) Revising Article for Intellectual Content: Tognetti, Pelligra, Citi
Category 3
(a) Final Approval of the completed Article: Vezzosi, Puccinelli,
Tognetti, Pelligra, Citi
CONFLICT OF INTEREST
The authors have no conflict of interest to declare.
ORCID
Rosalba Tognetti https://orcid.org/0000-0001-8449-9176
Simonetta Citi https://orcid.org/0000-0001-8211-9248
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How to cite this article: Vezzosi T, Puccinelli C, Tognetti R,
Pelligra T, Citi S. Radiographic vertebral left atrial size: A
reference interval study in healthy adult dogs. Vet Radiol
Ultrasound. 2020;1–5. https://doi.org/10.1111/vru.12896