Journal of Veterinary Cardiology (2021) 34, 55e63

www.elsevier.com/locate/jvc

Two radiographic methods for assessing

left atrial enlargement and cardiac
remodeling in dogs with myxomatous
mitral valve disease
T. Vezzosi, DVM, PhD, C. Puccinelli, DVM, S. Citi, DVM, PhD*,
R. Tognetti, DVM, PhD

Department of Veterinary Sciences, University of Pisa, Via Livornese lato monte, 56122
San Piero a Grado, Pisa, Italy

Received 24 July 2020; received in revised form 3 January 2021; accepted 5 January 2021

KEYWORDS Abstract Introduction: Two radiographic measures of the left atrial (LA) size, the
Vertebral left atrial vertebral left atrial size (VLAS) and the radiographic left atrial dimension (RLAD),
size; have been described in dogs. The aim of this study was to determine their feasibil-
Radiographic left atrial ity and diagnostic value in the prediction of LA enlargement and clinical stage in
dimension; dogs with myxomatous mitral valve disease (MMVD).
Preclinical stage; Animals: 111 client-owned dogs affected by MMVD.
Radiology; Methods: Retrospective study. In each dog, VLAS, RLAD, vertebral heart score
Cardiology (VHS), and left atrium-to-aorta-ratio (LA/Ao) were measured. The correlation be-
tween VLAS, RLAD, and LA/Ao was evaluated. The diagnostic accuracy of VLAS
and RLAD was assessed for the detection of LA enlargement and clinical staging
using the receiver operating characteristic curve analysis.
Results: A positive correlation was observed between VLAS, RLAS, and LA/Ao
(r ¼ 0.816 and r ¼ 0.855, respectively; p<0.0001). Both VLAS (area under the curve
[AUC], 0.93; p<0.0001) and RLAD (AUC, 0.98; p<0.0001) showed high diagnostic ac-
curacy in the detection of LA enlargement. In the stage B, the RLAD (AUC, 0.99;
cutoff, 1.8; sensitivity, 100%; specificity 93%) performed better than VLAS (AUC,
0.90; cutoff, 2.4; sensitivity, 66%; specificity 100%) and VHS (AUC, 0.89; cutoff,
10.7; sensitivity, 88%; specificity 83%) in the detection of dogs fulfilling the echo-
cardiographic criteria for stage B2.
Conclusions: VLAS and RLAD represent useful radiological tools for the detection of
LA enlargement in dogs with MMVD. In asymptomatic dogs, the RLAD performs

* Corresponding author.
E-mail address: simonetta.citi@unipi.it (S. Citi).

https://doi.org/10.1016/j.jvc.2021.01.002
1760-2734/ª 2021 Elsevier B.V. All rights reserved.
56
better than VLAS and VHS in the prediction of those fulfilling the echocardiographic
criteria for stage B2.
ª 2021 Elsevier B.V. All rights reserved.
Abbreviations
ACVIM American College of Veterinary
Internal Medicine
AUC area under the curve
ICC intraclass correlation coefficient
LA left atrial
LA/Ao left atrium-to-aorta ratio
LV left ventricular
MMVD myxomatous mitral valve disease
RLAD radiographic left atrial dimension
VHS vertebral heart score
VLAS vertebral left atrial size
Introduction
Myxomatous mitral valve disease (MMVD) is the
most common acquired cardiac disease in dogs
[1]. Mitral regurgitation is the hemodynamic
consequence of MMVD, which can lead to left
atrial (LA) and left ventricular (LV) remodeling
and possibly to congestive heart failure. Left
atrial enlargement is considered a major indica-
tor of mitral regurgitation severity and it has
been recognized as a strong predictor of outcome
in dogs with MMVD [2]. Although transthoracic
echocardiography is the non-invasive, gold
standard method used to assess LA size in dogs
with MMVD [3], it is not always possible to per-
form because of the cost of the examination, and
the knowledge and equipment required, or
because of the critical clinical condition of some
patients. Thoracic radiography is easily available,
less expensive, and faster to perform. It is
strongly recommended for the clinical staging of
MMVD in dogs, especially for the assessment of
cardiomegaly, pulmonary congestion, and pul-
monary edema [3,4]. Two indexes of radiographic
LA size, the radiographic left atrial dimension
(RLAD) [5e7] and the vertebral left atrial size
(VLAS) [8] have been described in dogs with
MMVD. A reference interval study on VLAS in dogs
was recently reported [9].
The aim of this study was to determine the
feasibility, the diagnostic value, and the optimal
cutoffs of VLAS and RLAD in the prediction of LA
enlargement in dogs with MMVD, and to evaluate
the clinical utility of these parameters in the
T. Vezzosi et al.
staging of the disease. We hypothesized that both
radiographic measurements had good diagnostic
accuracy in the assessment of LA size and
acceptable measurement variability.
Animals, materials and methods
The study was retrospective and observational;
therefore, no institutional animal care and use
approval or client consent were sought. All dogs
were recruited from the Department of Veterinary
Sciences of the University of Pisa.
Case selection
Medical records between January 2015 and April
2020 were reviewed for client-owned dogs with a
diagnosis of MMVD. Dogs were defined as being
affected by MMVD based on history, physical
examination, thoracic radiographs, and echo-
cardiography. Dogs were clinically classified into
stages B1, B2, C, and D according to the to the
most recent guidelines of the American College of
Veterinary Internal Medicine (ACVIM) [3]. Stage B
was defined as subclinical MMVD without (B1) or
with (B2) evidence of left cardiomegaly. For the
assessment of left cardiac enlargement, echo-
cardiography was considered the gold standard
method. A value of left atrium-to-aorta ratio (LA/
Ao) 1.6 was used to define LA enlargement [3].
An LV end diastolic diameter normalized for body
weight 1.7 was considered indicative of LV
enlargement [3]. Asymptomatic dogs were
assigned to stage B1 if presenting no echocardio-
graphic evidence of left cardiomegaly, or if pre-
senting only LA or LV enlargement. Asymptomatic
dogs were assigned to stage B2 if presenting both
LA and LV enlargement based on echocardiog-
raphy. Dogs were assigned to stage C if they had a
history or current clinical signs of CHF in con-
junction with past or current evidence of pulmo-
nary on thoracic radiographs. Finally, dogs with
past or current evidence of pulmonary on thoracic
radiographs that had been treated and relapsed or
failed to respond to the initial treatment were
classified as stage D.
Radiographic left atrial size in mitral valve disease
All dogs had to have undergone an echocardio-
graphic examination within 24 h before or 7 days
after the radiographic examination. All patients
had to have at least one right lateral radiographic
view. Body weight >20 kg, malposition of the
patient on thoracic radiographs (e.g. true abnor-
mal position of the thoracic vertebral column and
the trachea, or rotation of the thorax along its long
axis), thoracic vertebral abnormalities, con-
comitant presence of other cardiac disease or
pericardial effusion at the echocardiographic
examination were considered criteria for
exclusion.
Thoracic radiography
Thoracic radiographs were taken using a high-
frequency digital radiography system.a For each
dog, the right lateral radiographic view was used
to measure VLAS, RLAD, and the vertebral heart
score (VHS), using a free and open source code
software program.b
The VLAS was measured as established by Mal-
colm et al. [8]. A line was measured from the
center of the most ventral aspect of the carina to
the most caudal aspect of the LA where it inter-
sected with the dorsal border of the caudal vena
cava. Similarly to the VHS method, the same line
was then positioned over thoracic vertebrae
beginning at the cranial edge of the fourth thora-
cic vertebra and the number of vertebral units was
estimated to the nearest 0.1 vertebral body length
(Fig. 1).
The RLAD was obtained as described by Sal-
guero et al. [7]. For the measurement, the VHS
short axis was repositioned at the level of the
dorsal edge of the caudal vena cava. A line was
measured bisecting the 90 angle formed by the
intersection of the VHS long and short axes,
starting from this point to the dorso-caudal edge
of the LA. The same line was then repositioned
over the thoracic vertebrae and expressed in
vertebral body units to the nearest 0.1 vertebra,
as for VHS (Fig. 2).
The VHS was measured as described by
Buchanan et al. [10]. Briefly, the long axis of the
heart was measured from the ventral border of
left main stem bronchus to the outermost cau-
doventral margin of the cardiac apex. The short
axis was measured in the central third region of
a
MAXIVET 400 HF, Multimage srl, Varese, Italy.
b d
Horos, Horosproject.org, Nimble Co LLC d/b/a Purview in
Annapolis, MD, USA.
57
the heart, perpendicular to the long axis, from
the cranial to caudal border of the widest portion
of the heart. Measurements of both the long and
short axes were then positioned over the thoracic
vertebrae, parallel to the vertebral canal,
beginning at the cranial edge of the fourth
thoracic vertebra, and the number of vertebral
units was estimated to the nearest 0.1 vertebral
body length. The sum of the two measurements
was used to calculate the VHS.
All radiographic measurements were obtained
by an experienced radiologist (S.C.). To assess
the intra- and inter-observer measurement vari-
ability of VLAS and RLAD, the same operator
(S.C.) and a radiology PhD student
(C.P.) reviewed the right lateral thoracic radio-
graphic image of 12 randomly selected dogs (4
from the group B1, 4 from the group B2, and 4
from the group C) on three separate occasions,
each of them 7 days apart. The measurements
were performed independently and on a random
basis by the two investigators, blinded about
owner name, dog information and previous
measurements. The randomization was obtained
with the ‘randbetween’ function of the excel
software.c
Echocardiography
All echocardiographic examinations were carried
out by an experienced operator (T.V.) using an
ultrasonographic unitd equipped with electronic
phased-array transducers and a simultaneous
single-lead electrocardiogram. Unsedated dogs
were examined in right and left lateral recum-
bency. Each dog underwent a complete echo-
cardiographic examination, which included
transthoracic two-dimensional, M-mode, and Dop-
pler imaging [11]. The same operator measured
the LA/Ao according to the two-dimensional
method described by Hansson et al. [12]. The
severity of LA enlargement was classified accord-
ing to the LA/Ao into normal-to-mild (1.9) and
moderate-to-severe (>1.9). The LV end diastolic
diameter was measured on the M-mode echo-
cardiogram, obtained from the right parasternal
short-axis view [13]. All measurements were per-
formed evaluating 3e5 cardiac cycles, and mean
values were calculated.
c
Microsoft Office 365, Microsoft Corporation, Redmond, WA,
USA.
Aplio 300, Canon Medical Systems Europe, Zoetermeer,
Netherlands.
58 T. Vezzosi et al.

Fig. 1 Vertebral left atrial size measurement of one of
the dogs in the study. 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 inter-
sected with the dorsal border of caudal vena cava. The
same line was then positioned over thoracic vertebrae
beginning at the cranial edge of the fourth thoracic
vertebra and the number of vertebral units was esti-
mated to the nearest 0.1 vertebral body length.
Fig. 2 Radiographic left atrial dimension measure-
ment in the same dog in Fig. 1. To perform the meas-
urement, the vertebral heart score (VHS) short axis was
repositioned at the level of the dorsal edge of the caudal
vena cava. A line was measured bisecting the 90 angle
formed by the intersection of the VHS long and short
axes, starting from this point to the dorsal-caudal edge
of the left atrium. The same line was then repositioned
over the thoracic vertebrae and was expressed in ver-
tebral body units to the nearest 0.1 vertebra.

Statistical analysis
were chosen based on the highest of various
combinations of sensitivity and specificity using
Statistical analyses were performed using com-
the Youden index. Comparison between different
mercial statistical softwares.e,f,g Normality was
receiver operating characteristic curves was per-
assessed by the ShapiroeWilk test. Descriptive
formed using a non-parametric method [14].
statistics were calculated, and median and range
An intraclass correlation coefficient (ICC) was
were reported for each variable. Continuous vari-
used to quantify intraobserver and interobserver
ables were compared using the KruskaleWallis
measurement agreement for VLAS and RLAD. For
test. The correlation between VLAS, RLAD, and
ICC calculations, a two-way single measures mixed
LA/Ao was analyzed using a Spearman correlation
effect model for absolute agreement was used
analysis. Receiver operating characteristic curve
[15]. The agreement of the investigators per-
analysis was performed to assess the diagnostic
forming the measurements was considered poor if
accuracy of VLAS and RLAD in detecting the pres-
the value was 0e0.2, fair if 0.21e0.40, moderate if
ence of LA enlargement. Similarly, the diagnostic
0.41e0.6, substantial if 0.61e0.8, and almost
accuracy of VLAS and RLAD in the distinction
perfect if 0.81e1 [16]. Statistical significance was
between normal-to-mild and moderate-to-severe
set at p<0.05 for all analyses.
LA enlargement was assessed. Lastly, the diag-
nostic accuracy of VLAS, RLAD, and VHS (and a
combination of these variables) for the prediction
of the ACVIM stage was evaluated. The area under Results
the receiver operating characteristic curve (AUC)
was used as a summary measure for diagnostic In accordance with the inclusion criteria, 143 dogs
accuracy. Diagnostic cutoffs for each variable were initially selected. However, in 32/143 dogs, it
was not possible to accurately measure the RLAD
because the dorsal margin of the LA was not
e clearly distinguishable for the following reasons:
GraphPad Prism 5.0, GraphPad Software Inc, San Diego, CA,
USA. presence of a pronounced perihilar interstitial-
f
IBM SPSS Statistics 21.0; IBM Corporation Armonk, New York, alveolar lung pattern, or because of the over-
USA. lapping of the dorsal margin of the LA with the
g
MedCalc 19.3.1; MedCalc Software Ltd, Ostend, Belgium.
Radiographic left atrial size in mitral valve disease 59

Table 1 Echocardiographic and radiographic variables of cardiac size in 111 dogs with myxomatous mitral valve
disease.
Variable Stage B1 Stage B2 Stage C
No. of dogs 47 32 32
LA/Ao 1.4 (1.2e1.8) 2.0 (1.7e3.0)a 2.5 (1.8e3.2)a,b
LVIDDn 1.5 (1.1e1.8) 1.9 (1.7e2.4)a 2.1 (1.6e2.5)a,b
VLAS (No. of vertebrae) 2.1 (1.5e2.3) 2.5 (1.8e3.5)a 2.8 (2.0e3.6)a,b
RLAD (No. of vertebrae) 1.4 (1.1e2.0) 2.4 (1.8e3.3)a 2.8 (1.8e3.7)a,b
VHS (No. of vertebrae) 10.4 (9.2e11.6) 11.4 (9.9e13.6)a 12.3 (10.6e13.5)a,b
Values represent the median (range).
LA/Ao: left atrium-to-aorta ratio; LVIDDn: left ventricular end diastolic diameter normalized for body weight; RLAD: radiographic
left atrial dimension; VHS: vertebral heart score; VLAS: vertebral left atrial size.
a
p<0.05 in comparison to B1.
b
p<0.05 in comparison to B2. See text for definition of stages B1, B2, and C.

Fig. 3 Scatter plots of the LA/Ao, VLAS, and RLAD in the different American College of Veterinary Internal Medicine
(ACVIM) stages. The bars represent median and interquartile range. LA/Ao: left atrium-to-aorta ratio; RLAD: radio-
graphic left atrial dimension; VLAS: vertebral left atrial size.

caudal pulmonary vessels, the aorta and/or a rib.
Similarly, among these 32 cases, in 11 dogs, it was
not possible to measure the VLAS because the
intersection point between the caudal vena cava
and the caudal cardiac margin of the cardiac sil-
houette was not clearly visible.
The final study population considered for stat-
istical analysis was therefore composed of 111
dogs affected by MMVD, of which 47 were classified
as stage B1, 32 as stage B2, and 32 as stage C. The
group comprised 63 males and 48 females, with a
median age of 11 years (range, 4e18 years) and a
median body weight of 8.5 kg (range,
1.5e20.0 kg). Twenty-two dogs weighed <5 kg, 48
dogs weighed 5 to <10 kg, and 41 weighed 10 to
20 kg. The breeds represented in the study were
mixed breed (n ¼ 38), Cavalier King Charles
Spaniel (n ¼ 10), Pomeranian (n ¼ 10), Chihuahua
(n ¼ 9), Miniature Poodle (n ¼ 9), Dachshund
(n ¼ 6), Cocker Spaniel (n ¼ 4), Miniature Pinscher
(n ¼ 4), Jack Russell Terrier (n ¼ 3), West Highland
White Terrier (n ¼ 3), Maltese (n ¼ 2), Pekingese
(n ¼ 2), Shih-Tzu (n ¼ 2), and each of remaining
dogs belonged to other breeds.
Radiographic and echocardiographic data of all
the study population are reported in Table 1 and
Fig. 3. According to the LA/Ao, 40 dogs did not
have LA enlargement, 20 dogs had mild LA
enlargement, and 51 had moderate-to-severe LA
enlargement. A positive linear correlation was
observed between VLAS and LA/Ao (r ¼ 0.816,
p<0.0001) and between RLAD and LA/Ao
(r ¼ 0.855, p<0.0001; Fig. 4).
The optimal cutoffs for VLAS and RLAD for the
detection of LA enlargement were 2.2 (AUC,
0.93; 95% confidence interval [CI] 0.88e0.97;
sensitivity, 90%; specificity 80%; p<0.0001) and
1.8 (AUC, 0.98; 95% CI 0.95e1; sensitivity, 90%;
specificity 95%; p<0.0001), respectively. The
diagnostic accuracy of RLAD was significantly
higher than VLAS in detecting LA enlargement
(p¼0.0192; Fig. 5A). The best cutoffs for the dis-
tinction of normal-to-mild versus moderate-to-
severe LA enlargement were 2.4 for the VLAS
(AUC, 0.92; 95% CI 0.87e0.94; sensitivity, 80%;
specificity 87%; p<0.0001) and 2.0 for the RLAD
(AUC, 0.92; 95% CI 0.87e0.97; sensitivity, 92%;
specificity 78%; p<0.0001).
The diagnostic cutoffs of VLAS, RLAD, and VHS
for the detection of stage B2 are reported in Table
2. The diagnostic accuracy of RLAD was sig-
nificantly higher than VLAS (p¼0.0142; Fig. 5B) and
VHS (p¼0.0147) in the distinction between B1 and
B2 cases. The diagnostic accuracy of a combination
60 T. Vezzosi et al.

Fig. 4 Positive linear correlations between the two radiographic measures of left atrial size evaluated in the present
study and the LA/Ao: used as the echocardiographic gold standard of left atrial dimension. LA/Ao: left atrium-to-aorta
ratio; RLAD: radiographic left atrial dimension measurement; VLAS: vertebral left atrial size measurement.

Fig. 5 Comparison of receiver operating characteristic curves of VLAS and RLAD in the detection of left atrial
enlargement (Fig. 5A) and in the distinction between B1 and B2 cases (Fig. 5B). RLAD: radiographic left atrial
dimension; VLAS: vertebral left atrial size.

of VHS with VLAS (VLAS2.4 þ VHS10.7; Discussion

AUC ¼ 0.81; sensitivity 63%, specificity 100%) was
not higher than using VLAS alone (VLAS2.4; Table
2) in the prediction of stage B2 (p¼0.33). Similarly,
a combination of VHS with RLAD
(RLAD1.8 þ VHS10.7; AUC ¼ 0.92; sensitivity
88%, specificity 98%) was not more accurate than
using RLAD alone (RLAD1.8; Table 2) in the pre-
diction of stage B2 (p¼0.07).
In terms of intraobserver measurement agree-
ment, both VLAS and RLAD methods showed an
excellent agreement with an ICC of 0.97
(0.74e0.99) and 0.99 (0.95e1.00), respectively.
Similarly, in terms of interobserver measurement
agreement, both VLAS and RLAD methods showed
excellent agreement with an ICC of 0.96
(0.91e0.99) and 0.97 (0.92e0.99), respectively.
In our study, we compared the diagnostic value of
two new radiographic parameters (VLAS and RLAD)
for the assessment of LA enlargement in dogs with
MMVD and their utility in the clinical staging of the
disease. Both measurements were feasible in most
dogs; however, the RLAD was not measurable in 32
cases (22%) and the VLAS was not measurable in 11
cases (7%). The higher feasibility of VLAS in com-
parison to RLAD can be explained by the fact that
the identification of the landmarks for the meas-
urement of VLAS (i.e. the carina and the point of
intersection between the most caudal aspect of
the LA and the dorsal border of the caudal vena
cava) are more easily identifiable than the dorsal
margin of the LA, which represents one of the
Radiographic left atrial size in mitral valve disease
Table 2 Results of receiver operating characteristic curve analysis and diagnostic cutoffs of vertebral left atrial
size, radiographic left atrial dimension, and vertebral heart score in the prediction of dogs fulfilling the echo-
cardiographic criteria for stage B2.
Parameter AUC 95% CI
VLAS 0.90 0.83e0.98
RLAD 0.99 0.98e1.00
VHS 0.89 0.82e0.97
AUC: area under the receiver operating characteristic curve; CI: confidence interval; RLAD: radiographic left atrial dimension; Se:
sensitivity; Sp: specificity; VHS: vertebral heart score; VLAS: vertebral left atrial size.
Diagnostic cutoffs for each variable were chosen based on the highest of various combinations of sensitivity and specificity using
the Youden index.
landmarks for measuring the RLAD. The presence
of cardiogenic pulmonary edema, with perihilar
and/or dorso-caudal distribution, may obscure the
dorsal margin of the LA. Furthermore, the dorsal
margin of the LA can overlap with other anatomi-
cal structures with radiopacity of soft tissues (such
as the aorta and pulmonary vessels of the caudal
lung lobes) and/or ribs, making its clear identi-
fication more difficult. In previous studies on VLAS
and RLAD in dogs, no limitations of the feasibility
of these methods were reported [5e8,17,18]. In
the study by Salguero et al., dogs with pulmonary
edema were excluded from the analysis [7]. How-
ever, these limitations must be considered for the
clinical use of such radiographic methods. In cases
in which neither the VLAS nor the RLAD are
measurable, the VHS remains the main objective
method to radiographically assess cardiac
enlargement.
In our study, a strong positive correlation was
found for VLAS and RLAD with the LA/Ao in
accordance with previous studies on dogs with
MMVD [7,8]. The best cutoff of RLAD to detect LA
enlargement was 1.8 in our study, which is the
same as previously described by Salguero et al. [7],
and a RLAD  2.0 was the best predictor of
moderate-to-severe LA enlargement. Regarding
VLAS, our results showed that the best cutoff to
detect LA enlargement was 2.2, which is very
similar to the previously described cutoff of 2.3
reported by Malcolm et al. [8] and in line with a
recent study reporting 2.2 as the upper limit of the
reference range of VLAS in healthy dogs [9]. A VLAS
2.4 was the best predictor of moderate-to-severe
LA enlargement. In our study, the RLAD showed a
higher diagnostic accuracy in detecting LA
enlargement than the VLAS. A possible explanation
is that LA mainly enlarges in a dorso-caudal
direction, with secondary dorsal displacement of
the tracheal bifurcation on latero-lateral chest
radiographs [4]. The RLAD probably better
61
Cutoff (N. of vertebrae) Se (%) Sp (%) p-Value
2.4 66 100 <0.0001
1.8 100 93 <0.0001
2.1 71 100
10.7 88 83 <0.0001
11.6 22 100
highlights this geometrical pattern of LA enlarge-
ment in comparison to VLAS.
Regarding the utility of VLAS and RLAD in the
staging of dogs with MMVD, both methods showed a
good diagnostic accuracy for the prediction of the
ACVIM stage in asymptomatic dogs (i.e. B1 vs. B2).
The current ACVIM guidelines recommend the use
of VHS in the staging of dogs with MMVD and sug-
gest the possible utility of VLAS in the detection of
LA enlargement [3]. Our results are in line with
two recent studies agreeing that the optimal cut-
off of VLAS in the prediction of the B2 stage is 2.5
[17,18]. However, our results showed that the
RLAD (cutoff 1.8) performs better than VLAS in the
distinction between B1 and B2 cases. This cutoff
showed a high sensitivity (100%), limiting false-
negative results. Conversely, the maximum spe-
cificity (100%) cutoff of RLAD for the prediction of
dogs fulfilling the echocardiographic criteria for
stage B2 was 2.1, thus minimizing false-positive
results. In our study, the best cutoff of VHS in
predicting dogs fulfilling the echocardiographic
criteria for stage B2 was 10.7, in line with the
cutoff recommended by the current ACVIM guide-
lines (10.5) [3]. However, the addition of the VHS
did not increase the diagnostic accuracy compared
to RLAD alone in our study.
Our results thus suggest that using a radio-
graphic index of LA enlargement (RLAD if meas-
urable or VLAS as an alternative) may be useful in
the staging of asymptomatic dogs with MMVD,
especially if echocardiography is not available.
Despite this, standard echocardiography remains
the gold standard to assess cardiac enlargement
for the diagnostic and therapeutical management
of dogs with MMVD in clinical practice [3].
Our results should be considered within the
context of the study’s limitations. First, the LA/Ao
method was used as the gold standard to define LA
enlargement. Although LA/Ao is the most com-
monly used method for the evaluation of LA size
62
for decision-making in canine MMVD [3,19,20], it is
considered less sensitive than other linear or
volumetric echocardiographic measures of LA size,
and it can be subject to significant interoperator
variability [21e23]. Second, in terms of intra-
observer and interobserver variability, all radio-
graphic measurements were performed by
operators working in radiology. Thus, the varia-
bility found in this study may not be applicable to
non-radiology colleagues (e.g. general practi-
tioners, cardiologists, intensive care clinicians).
Third, for the purpose of the study, only radio-
graphs of good quality for an accurate measure-
ment of both radiographic parameters were
considered for the analysis. Thus, different results
may occur if only low-quality thoracic radiographs
are available (e.g. critical, severe panting, or not-
compliant dogs). However, the authors believe
that VLAS and RLAD can become particularly useful
in the severity assessment of asymptomatic dogs
with MMVD (stage B), possibly helpful in stratifying
the risk of congestive heart failure and/or cardiac
death, with higher indication for performing fur-
ther diagnostic workup (e.g. echocardiography,
cardiac biomarkers). Further studies evaluating
the measurement variability among non-radiology
operators, as well as the prognostic significance
of these radiographic parameters, are warranted.
Forth, thoracic radiographs were acquired within a
maximum of 7 day from echocardiography. Possi-
ble influence of cardiovascular drugs used in the
meanwhile on LA size was not considered. How-
ever, in almost all dogs, both examinations
(thoracic radiographs and echocardiography) were
performed on the same day as a complementary
cardiorespiratory diagnostic workup. Lastly, the
influence of the breed on VLAS and RLAD was not
evaluated in the present study, and to the authors’
knowledge nor in previous studies. Since breed-
related differences were described for radio-
graphic heart measurements [24,25], further
studies evaluating this possible influence on these
new radiographic tools are needed.
Conclusions
This study showed that VLAS and RLAD are useful
radiological tools for detecting LA enlargement in
dogs with MMVD, and are valuable in the severity
assessment and clinical staging of the disease. In
asymptomatic dogs, the RLAD performs better
than VLAS and VHS in predicting those fulfilling the
echocardiographic criteria for stage B2.
T. Vezzosi et al.
Conflict of Interest Statement
The authors do not have any conflicts of interest to
disclose.
Acknowledgments
This research received no grant from any funding
agency in the public, commercial, or not-for-profit
sectors.
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