Received: 6 December 2020 Revised: 13 May 2021 Accepted: 14 May 2021

DOI: 10.1111/vru.13004

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

Echocardiographic changes in the shape and size of the aortic

cusps in dogs with confirmed systemic hypertension

Merrilee Holland Erik Hofmeister Judith Hudson

Framingham Heart Study clinic, Auburn

University College of Veterinary Medicine,
Auburn, Alabama, USA
Correspondence
Merrilee Holland, Auburn University College of
Veterinary Medicine, Auburn, Al.
Email: hollame@auburn.edu
EQUATOR network disclosure: an EQUATOR
network checklist was not used
Previous presentation disclosure: portions of
this study were presented at the 2020 ACVR
Virtual Conference
Abstract
Systemic hypertension (SH) in dogs typically occurs secondary to renal disease, dia-
betes mellitus, hyperadrenocorticism, malignant adrenal tumors, or various medica-
tions. Echocardiography performed on people with SH has shown asymmetric dila-
tion of the sinuses at the level of the aortic valves, previously undescribed in canine
patients. The objective of this retrospective case-control study was to determine if
there was a difference in size and shape of the aortic cusps at the level of the sinus of
Valsalva in dogs with SH compared to dogs with normal blood pressure. We reviewed
echocardiographic findings in 74 dogs with SH and 37 dogs with normal blood pressure
(NBP), defined as less than 150 mmHg. Systemic hypertension was classified as mild
(150-159 mm Hg), moderate (160-179 mm Hg), or severe (greater than 180 mm Hg).
There was a significant difference (P < .001) in the mean size of the aorta cusps at the
level of the sinuses in 67 of 74 dogs with SH and none of 37 dogs with NBP. Of the 74
dogs with SH, 70 had left ventricular hypertrophy (18 asymmetric, 15 concentric, and
37 eccentric). Additionally, there was aortic root dilatation in 15 dogs, aortic insuffi-
ciency in 21, mitral regurgitation in 50, and left atrial enlargement in 71. The standard
deviation of the three cusp measurements between the dogs with SH and dogs with
NBP had a sensitivity of 92% and specificity of 97% for diagnosis of SH. Asymmetric
size of the aortic cusps on echocardiography is therefore a reliable indicator of SH in
dogs.

KEYWORDS
aortic cusps, aortic root dilatation, dog, systemic hypertension, target organ damage

1 INTRODUCTION aortic aneurysm, and left-sided congestive heart failure as evidence

Echocardiographic findings in people, dogs, and cats with systemic
hypertension (SH) include normal ventricular wall thickness to vari-
able degrees of left ventricular hypertrophy.1–10 The most recent SH
guidelines from the American College of Veterinary Internal Medicine
(ACVIM) in 2018 recognized concentric left ventricular hypertrophy,
Abbreviations: ACVIM, American College of Veterinary Internal Medicine; CV, coefficient of
variation; IVS, interventricular septum; LA/Ao, left atrium to aorta ratio; LVFW, left
ventricular free wall; LVID, left ventricular internal diameter; NBP, normal blood pressure; SH,
systemic hypertension; UPC, urine protein to creatinine ratio.
of target organ damage in both dogs and cats with SH.1,2 Left ven-
tricular hypertrophy is an inconsistent finding of SH in people.5,6
Aortic aneurysm formation11 and left-sided heart failure7,12 have
been associated with long standing SH in people. Aortic dilata-
tion has been included as a complication of SH in dogs and cats2
and, in people, precedes or occurs independently of left ventricular
hypertrophy.5,6 Case reports of both feline and canine patients identi-
fied aortic dilation/aneurysm and aortic dissection secondary to SH on
echocardiograms.13–16 Aortic root dilatation and mitral insufficiency
was reported in 30 dogs with SH with 10 of 30 having concurrent

Vet Radiol Ultrasound. 2021;1–8. wileyonlinelibrary.com/journal/vru © 2021 American College of Veterinary Radiology 1
2 HOLLAND ET AL .
aortic insufficiency.3 M-mode echocardiograms performed on 75 cats
with SH showed that 15 of 68 had left atrial enlargement and four of 67
had an aortic diameter above the normal range.10 In a different study,
variable left ventricular hypertrophy and increased distal aortic root
measurements were noted in 15 cats with SH with no differences in the
left atrium to aorta ratio (LA/Ao) as compared to the control group.4
A longitudinal echocardiographic study that followed aortic root
remodeling in people over 16 years found greater aortic root dilata-
tion with the presence of SH or obesity and both factors together
resulted in greater aortic dilatation.17 Greater dilatation has been con-
sistently reported in hypertensive compared to normotensive patients
or patients with optimal control of SH.5,6,18,19 In people with SH or
genetic conditions resulting in aortic aneurysms, asymmetric dilata-
tion of the aortic sinuses and asymmetric size and shape of the aor-
tic cusps have been noted on echocardiographic examinations.11 Aor-
tic root dilatation in people with SH is now considered as target organ
damage as the result of SH5,6,20 and has been associated with increased
cardiovascular risk regardless of the presence of left ventricular hyper-
trophy or other comorbidities.6,12,21
Left atrial enlargement on echocardiography is a common and early
sign of hypertensive heart disease in people with and without echocar-
diographically detected left ventricular hypertrophy and results in
increased risk for a major cardiovascular event.22,23 In a human study,
left atrial dilatation was found to be a strong independent predictor of
increased risk of cardiovascular events and considered as target organ
damage in middle aged SH patients.24 Conversely, only one case report
noted enlargement of the left atrium in an SH dog.15 The left atrium
and/or LA/Ao was increased in cats with SH in two case reports and in
only 15 of 68 cats with SH when measured in a study of 75 cats.10,13,14
The objective of the current study was to investigate the size and
shape of the aortic cusps at the level of the sinus of Valsalva on echocar-
diography of dogs with SH and dogs with normal blood pressure. Our
goal was to further define changes to the left ventricle, aortic root, and
left atrium in dogs with SH. Our hypothesis was that there would be
asymmetry in the size and shape of the aortic cusps in the dogs with SH
compared to the dogs without SH.
2 MATERIALS AND METHODS
This was a retrospective case control study evaluating echocardio-
grams and blood pressures obtained of dogs presenting to the Auburn
University College of Veterinary Medicine between 2008 and 2019.
Institutional Animal Care and Use Committee approval was not
required for this retrospective study, however the hospital director
approved the use of patient data. Blood pressures were measured
using the Doppler method by trained veterinary technicians on the
same day as the echocardiograms. Systemic hypertension was classi-
fied as mild (150-159 mm Hg), moderate (160-179 mm Hg), or severe
(greater than 180 mm Hg). Blood pressure less than 150 mm Hg was
considered normal.1 The urine protein to creatinine ratio (UPC) was
recorded as normal if < 0.5.25 Medical management was recorded if ini-
tiated for the SH dogs.
Decisions for inclusion or exclusion were made by a board-certified
veterinary radiologist (M.H., American College of Veterinary Radiol-
ogy) with over 30 years of experience. Some dogs were included in
the SH group because alterations in the aortic cusps were noted on
echocardiography performed between 2008 and 2012 and review
of medical records confirmed SH. Most SH cases were identified by
reviewing the medical records of dogs presenting to various services
at the Auburn University College of Veterinary Medicine with preex-
isting conditions for SH listed on imaging requests received by the
first author (M.H.) from 2012-2019. Medical records were reviewed
to determine if each dog had been seen by the cardiology service for
an echocardiogram and if blood pressure was measured on the same
day. If blood pressure measured above 150 mm Hg, the echocardio-
gram was reviewed to determine if the aortic cusps could be clearly
visualized. Cases were excluded if the closed valves and center point
were not clearly visible on still images or video clips. All the dogs
with NBP were found by reviewing admission and medical records of
dogs presented to the cardiology service from 2016 to 2019. If medi-
cal records showed normal measurement of blood pressure, then the
echocardiogram was reviewed for ability to visualize the aortic cusps.
The discharge summary of the visit corresponding to the echocardio-
gram study was reviewed to identify the diagnosis, assessment, and
medications for each dog in this study.
Each echocardiographic parameter was measured in triplicate by
the veterinary radiologist (M.H.) using a DICOM viewer linear mea-
surement tool (RadiAnt Poznan, Poland; https://www.radiantviewer.
com/) and the mean was calculated for each variable obtained dur-
ing the same study. The interventricular septum (IVS), left ventricular
internal diameter (LVID), and left ventricular free wall (LVFW) in sys-
tole and diastole were measured primarily from M-mode tracings or
from recorded 2D images obtained from the right parasternal short
axis view. Aorta and left atrial sizes were measured in all SH dogs from
right parasternal short axis 2D images obtained at the heart base. In
the dogs with NBP, aortic diameter, IVS, and LVFW were remeasured
using the DICOM viewer three times from 2D still images and video
clips using the right parasternal short axis view obtained from the stan-
dard location.
For patients with SH, each measurement was compared to the ref-
erence interval with 95% prediction established by weight.27 If the
variable’s mean was within the predicted range based on weight then
the measurement was considered normal. If the mean was higher, the
measurement was designated as increased. Interventricular septum,
LVFW, and LVID measurements in systole and diastole were deemed
normal when all measurements were within the 95% prediction inter-
val. Mean thicknesses of the IVS and LVFW were compared in systole
and diastole between groups. Asymmetric classification was assigned
when one or more but not all the measurements of the IVS or LVFW
in systole and diastole were above the 95% prediction interval along
with normal LVID. Concentric classification was assigned when all mea-
surements of the IVS and LVFW in diastole and systole were above the
95% prediction interval with a normal LVID. Eccentric hypertrophy was
defined as normal to thickening of the IVS, LVFW, or both and dilation
of the LVID in systole and diastole. Aortic and left atrial mean diameter
HOLLAND ET AL .
F I G U R E 1 A, Two-dimensional image obtained using a phased
array, 5 MHz transducer of the aorta and left atrium at the heart base
of a dog with normal blood pressure of 140 mm Hg. B, Measurement of
the included two-dimensional image of the aortic cusps: right cusp
13.3 mm, left cusp 13.1 mm, and noncoronary cusp 13.1 mm [Color
figure can be viewed at wileyonlinelibrary.com]
measurements were assigned as increased when their values were
above the 95% prediction interval. The LA/Ao was considered
increased when greater than 1.3.27 Doppler tracings of regurgitant
flow velocity at the mitral and aortic valves were classified based on
written reports and review of still images or videos clips. Grading of
regurgitant flow as trivial, mild, moderate, or severe was made from
color Doppler images by noting jet size and distance traveled within the
left atrium for the mitral valve and the extent of the jet within the left
ventricular outflow tract for the aortic valve.27
Echocardiographic images of the aorta and left atrium were
excluded when malpositioned from published standard views of the
right parasternal short axis view at the heart base.28 Maximum size of
each of the three aortic cusps was measured from the inner diameter
to inner diameter three times in all SH and NBP dogs when the valves
were closed from the center point (Figures 1 and 2). Aortic cusps were
subjectively considered to be asymmetric in shape, when the difference
in mean value of the cusps varied more than 1.0 mm.
3
F I G U R E 2 A, Two-dimensional image obtained using a phased
array, 5 MHz transducer of the aorta and left atrium at the heart base
of SH dog with blood pressure of 270 mm Hg. B, Measurement of the
included 2D image of the aortic cusps: right cusp 17.4 mm, left cusp
15.4 mm, and noncoronary cusp 13.5 mm [Color figure can be viewed
at wileyonlinelibrary.com]
Statistical analyses were performed using commercial software
(SPSS 26.0, IBM SPSS statistics, New York, USA), by a researcher
(E.H.) with academic training in statistical analysis. The mean and
standard deviation of the IVS and LVFW were calculated for SH and
NBP dogs. Normality was determined using the D’Agostino-Pearson
method. Comparisons between SH and NBP groups were made with
a t-test for normally distributed data (cusp size mean, aorta diameter,
left atrial size, left atria size/aorta diameter) and with a Mann-Whitney
U test for non-normally distributed data (cusp size standard deviation,
coefficiency of variation, aorta cusp diameter/body weight, blood pres-
sure). A receiver operator curve (ROC) was used to determine the diag-
nostic sensitivity and specificity for aortic cusp variation in size (stan-
dard deviation and coefficient of variation). Significance was set at
P < .05.
4 HOLLAND ET AL .
3 RESULTS
Echocardiograms were acquired using one of two machines, with trans-
ducer arrays varying based on patient size (Phillips IE33 machine, Both-
ell, WA; transducer array of 1 to 12 MHz; or GE Vivid E9 machine,
Horton, Norway; transducer array of 1.4 to 12 MHz). Each dog was
placed on a cardiac table in lateral recumbency, with the dependent
side varying based on the preference of the observer. Imaging of the
dependent side was performed after clipping the hair or applying alco-
hol and ultrasound gel. Most echocardiograms of SH dogs were per-
formed by the hospital’s cardiology service (consisting of 3 board-
certified veterinary cardiologists [ACVIM] and one resident in training)
with a few being scanned by veterinary radiologists (M.H., J.H., Ameri-
can College of Veterinary Radiology), prior to having a the echocardio-
gram performed by the cardiology service. All measurements for SH
dogs were made using a standardized echocardiographic protocol,26
with a simultaneous electrocardiogram and the leading-edge method
from still images and stored video clips.
There were 74 dogs in the SH group. Abnormal aortic cusps were
noted in 12 dogs with SH during echocardiography performed by the
radiology service from 2008 to 2012. Sixty-two dogs were subse-
quently found by reviewing medical records of dogs presenting with
preexisting conditions for SH. These 74 dogs were referred to our insti-
tution or were imaged because of neoplasia (22), neurologic signs (15),
chronic renal disease (14), adrenal tumor/masses (5), hyperadrenocor-
ticism (4), diabetes (4), heart disease (4), protein losing nephropathy (4),
renal failure (1), and detached retina (1).
Blood pressures ranged from 150 to 300 mmHg and weights
were between 1.78 and 44 kilograms, age 1-17 years, and mean age
9.3 years. Medical treatment for SH was recorded in 43 of 74 dogs.
There were three intact females, 30 spayed females, seven intact males,
and 34 castrated males. The UPC ratio was performed in 37 of 74 dogs
with SH and was >0.5 in 35 of 37 dogs. Treatment for SH was pre-
scribed for 43 of 74 dogs. Breeds of dogs with SH included eight Poo-
dles, six mixed breed dogs, five Labrador Retrievers, four American
Cocker Spaniels, three Greyhounds, three Schnauzers, three Yorkshire
Terriers, two American Staffordshire Terriers, two Basset Hounds,
two Beagles, two Boston Terriers, two Chihuahuas, two Dachshunds,
two Dalmatians, two English Cocker Spaniels, two German Shepherd
dogs, two Golden Retrievers, two Jack Russell Terriers, two Cava-
lier King Charles Spaniels, two Shetland Sheepdogs, two Weimaran-
ers, two West Highland Terriers, and one dog each of 12 other
breeds.
There were 37 dogs in the NBP group with recorded blood pres-
sures ranging from 65 to 148 mm Hg. Weights ranged from 2.2 to 36.6
kilograms including 14 males and 23 females aged 5-15 years (mean
10.3 years). Dog breeds included seven Chihuahuas, six mixed breed
dogs, four Cavalier King Charles Spaniels, three Dachshunds, three
Yorkshire Terriers, two Dobermans, and one dog each of 12 other
breeds. On presentation, 23 of 37 dogs had cardiac disease asso-
ciated with mitral valve regurgitation alone, eight had mitral valve
regurgitation and pulmonary hypertension, two had pulmonary hyper-
tension alone, one had mitral valve regurgitation and heart block,
one had mitral valve regurgitation and atrial fibrillation, one had
dilated cardiomyopathy, and one had idiopathic pericardial effu-
sion. Using ACVIM guidelines for mitral regurgitation, five dogs
were Stage B1, 12 were Stage B2, nine were Stage C compen-
sated, two were Stage D compensated, and no classification was
listed for six dogs with mild mitral regurgitation and three with-
out mitral regurgitation.29 At the time of echocardiography, 19 dogs
were on no medications, six were on a combination of enalapril,
furosemide, and pimbobendan, two were receiving enalapril alone,
three were on a combination of enalapril and furosemide, two were
on sildenafil alone, one was on sildenafil and pimbobendan, one was
on benazapril, pimbobendan, sildenafil, and spirolactone, one was
on pimbobendan and sotolol, and one was on pimbobendan and
diltiazem.
Normal wall thickness of the IVS and LVFW was noted in four of
74 SH dogs. Concentric thickening of the IVS and LVFW with a normal
LVID was noted in 15 of 74 SH dogs. Asymmetric thickening was con-
sidered to be present in 18 of 74 SH dogs when one or more but not
all measurements of the IVS or LVFW were increased with a normal
LVID. Eccentric hypertrophy was noted when the LVID was increased
in diastole and systole in 37 SH dogs (4 normal thickness, 14 concentric
hypertrophy, and 19 asymmetric hypertrophy). Aortic diameter mea-
sured at the heart base was increased in 15 of 74 dogs with SH and
normal in all 37 dogs with NBP. None of the dogs with SH or NBD had
increased velocity at the aortic valves that would be consistent with
aortic stenosis.
When the shape of aortic cusps was evaluated, 67 of 74 dogs in the
SH group had at least one cusp measurement greater than 1.0 mm dif-
ferent from the other cusps. The other seven dogs with SH had differ-
ences in cusp measurements less than 1.0 mm. Of these seven, one had
concentric hypertrophy, two eccentric hypertrophy, and four asymmet-
ric hypertrophy. All dogs with NBP had differences in cusp measure-
ment less than 1.0 mm. In addition to the 74 dogs with SH that were
used in the study, there were 15 dogs with SH that could not be used
because aortic cusps could not be accurately visualized. The left atrium
was enlarged in 71 of 74 dogs with SH. The LA/Ao was increased in 56
of 74 dogs. Aortic insufficiency was present in 21 of 74 dogs with SH
(trivial in three, mild in five, moderate in 10, and severe in three). Mitral
regurgitation was present in 50 of 74 dogs with SH (trivial in 11, mild in
24, moderate in three, and severe in 12).
Comparison of variability (standard deviation and coefficient of
variation) in mean cusp size between dogs with NBP (Figure 1) and
dogs with SH (Figure 2) had a significant difference of P < .001. The
aorta diameter and left atria/aorta diameter were significantly differ-
ent between dogs with NBP and SH (P = .000048 and P < .00001,
respectively). There was no significant difference in left atrial size
(P = .25). Comparison of aortic cusp diameter normalized to weight
between NBP and SH groups had a significant difference between
groups of P = .04. Comparison of blood pressure between dogs with
NBP and dogs with SH had significant differences of P < .001 (Table 1).
Standard deviation was a significant predictor of SH, with an area under
the curve of 0.96 (95% CI: 0.92-1.0, P < .0001). Identification of SH
using the standard deviation of the three cusp measurements between
HOLLAND ET AL . 5

TA B L E 1 Mean ± standard deviation echocardiographic values for dogs with systemic hypertension or normal blood pressure

SH (n = 74) NBP (n = 37) P-value

Noncoronary AC 1 (mm) 10.1 ± .34 8.5 ± .26 N/A
Right AC 2 (mm) 11.8 ± .41 8.4 ± .26 N/A
Left AC 3 (mm) 9.7 ± .35 8.3 ± .25 N/A
Standard deviation of three aortic cusps (mm) 1.4 ± 0.8 0.1 ± 0.3 <.0001*
Average size of three aortic cusps (mm) 10.5 ± .35 8.4 ± .26 .0014*
Coefficient of variation 0.14 ± 0.06 0.02 ± 0.03 <.0001*
Average aortic cusp size/weight 0.85 ± 0.49 1.10 ± 0.57 .04*
Systolic blood pressure (mmHg) 194 ± 36 122 ± 19 <.0001*
Interventricular septum (diastole) (cm) 1.04 ± 0.27 0.79 ± 0.27 N/A
Interventricular septum (systole) (cm) 1.43 ± 0.36 1.19 ± 0.32 N/A
Left ventricular free wall (diastole) (cm) 0.92 ± 0.23 0.70 ± 0.19 N/A
Left ventricular free wall (systole) (cm) 1.37 ± 0.29 1.18 ± 0.24 N/A
Aorta diameter (cm) 1.96 ± .58 1.49 ± .44 .000048*
Left atrium (cm) 3.01 ± .69 3.20 ± 1.05 .25
Left atrium to aortic ratio 1.6 ± .31 2.2 ± .61 <.00001*

Notes: SH, systemic hypertension; NBP, normal blood pressure; N/A, not applicable. Absolute values for aortic cusp (AC) sizes were not compared between
groups. .
*
Indicates statistically significant difference.

dogs with NBP and dogs with SH had a sensitivity of 92% and a speci-
ficity of 97% for an SD over 0.31. The coefficient of variation (CV) was
a significant predictor of SH, with an area under the curve of 0.97 (95%
CI: 0.93-1.0, P < .0001). Using the CV of the three cusp measurements
between the dogs with NBP and those with SH, the reported sensitivity
was 96% and specificity was 95% for a CV over 0.035.
4 DISCUSSION
Findings supported our hypothesis that asymmetry of aortic cusps (size
and shape) would be an echocardiographic indicator of SH in dogs.
Noticeable variation in the shape of the aortic cusps at the level of the
sinuses of Valsalva was detected in 67 of 74 SH dogs and was not seen
in any of the 37 NBP dogs. Asymmetric aortic cusps were only seen in
the dogs with SH with the right aortic cusps typically larger than the
others. The variability in aortic cusp size was only noted in the dogs
with SH and was significantly different from dogs with normal blood
pressure.
Geometric complexity of the aorta at the sinuses of Valsalva may
allow the asymmetric sizes of the sinuses to be overlooked on an
echocardiogram.11 The aortic sinuses were not measured in our study
because alterations in aortic cusp shape and size were more read-
ily identifiable during real time imaging or review of still images and
video loops. Measurements of aortic cusps were made at the stan-
dardized location of the aortic root at the heart base at the level
of the left atrium. Our 74 dogs with SH had clearly visualized aor-
tic cusps and center points. We were unable to include some of the
SH cases seen at our institution due to poor visualization caused by
lung interference, poor axial resolution, and less commonly oblique
positioning.
Left ventricular hypertrophy associated with SH has been long
been considered a hallmark of target organ damage in dogs, cats, and
people.1,2,7,20 Asymmetric shape and size of the aortic cusps at the
level of the sinus of Valsalva occurred in 67 of 74 SH dogs and may
be the only indication of target organ damage from SH. In people with
higher systolic blood pressures, concentric hypertrophy occurs more
frequently than eccentric hypertrophy. Variability in the hypertensive
response relates to the severity, duration, or progression of increase in
blood pressure. Regression of concentric left ventricular hypertrophy
has been demonstrated with medical management of blood pressure
which decreases risk of cardiovascular events.7
Almost ninety-five percent of our dogs with SH had variable left ven-
tricular hypertrophy (20% concentric, 24% asymmetric, 50% eccentric)
and 5% had normal wall thickness. Our study was inconsistent with
the previously mentioned study of 30 dogs with SH as 16 of 30 (53%)
of dogs had normal wall thickness using the Cornell reference range.
Abnormal left ventricular geometry was noted in 14 of 30 dogs with
symmetric hypertrophy noted in 10 of 14 (71%) dogs and asymmet-
ric hypertrophy (defined as hypertrophy predominantly in the IVS or
LVFW) in four of 14 (29%) dogs with SH.3 Our findings were more con-
sistent with several studies of cats with SH which documented variable
left ventricular hypertrophy and fewer cats with SH in these studies
had normal left ventricular wall thickness.8–10 One feline study con-
cluded that the variable echocardiographic findings were insensitive
for screening for SH or prompting for blood pressure acquisition.10
The variable left ventricular remodeling in our dogs with SH was likely
due to the duration and severity of the SH. Asymmetric or eccentric
6 HOLLAND ET AL .
hypertrophy or normal wall thickness will not likely trigger concern for
SH as only concentric hypertrophy has been recognized as target organ
damage in veterinary medicine.1,2
Renal disease was the presenting complaint in 20 of 74 of our SH
dogs. Urine creatinine protein ratio was performed in 37 of 74 dogs
with SH and was >0.5 in 35 of 37 dogs. With any form of renal disease
with proteinuria, dogs had a worse prognosis and shorter survival time
when the UPC was >0.5.31 In a group of dogs with SH and renal impair-
ment from leishmaniasis, variable degrees of left ventricular hypertro-
phy was identified in 32 of 43 dogs, with only one dog having detectable
enlargement at the level of the aortic annulus and concurrent aortic
insufficiency.30 In our study, 35 dogs with SH and elevated UPC showed
variable left ventricular hypertrophy: 20 of 35 eccentric (concentric
11, asymmetric 9), eight of 35 concentric, and seven of 35 asymmet-
ric. This was similar to the findings of a study of people with SH and
chronic renal disease that found a higher prevalence of left ventricular
hypertrophy. In that study, the combined target organ damage of left
ventricular hypertrophy and chronic renal disease caused an increased
risk of a major cardiovascular events as compared to each of these fac-
tors alone.31
In our study, the aortic root diameter measured above the pub-
lished reference range in only 15 of 74 dogs with SH; however, val-
ues were significantly increased from the dogs with NBP. This finding
alone would not necessarily trigger concern for target organ damage
in veterinary medicine. In the previously mentioned study of 30 dogs
with SH, aortic root diameter was increased relative to the published
range in all SH dogs but was not significantly different from the con-
trol group.3 In the study of 15 cats with SH when the aorta was mea-
sured at four sites from a right parasternal longitudinal axis view, all SH
cats had a significantly larger aorta compared to the control group for
proximal ascending aorta and the ratios.4 The disparity in the size of
the aortic root to proximal ascending aorta was visualized in a few dogs
with SH when imaged from the longitudinal plane. Unfortunately, lon-
gitudinal imaging including the aortic root to the ascending aorta is not
routinely part of most echocardiographic studies. Aortic insufficiency
was noted in 21 of 74 of our dogs with SH (28%) similar to the previ-
ous study finding that condition in 10 of 30 (33%) of SH dogs.3 Mitral
regurgitation in our study was present in 50 of 74 (68%) dogs similar to
the previous study of 20 of 30 (66%) SH dogs.3 Aortic insufficiency has
been linked to increased size of the aortic root in cats, dogs, and peo-
ple with SH making this finding a trigger for obtaining systemic blood
pressure measurements.3,13,14,15,18
Aortic root dilatation has been extensively studied in people
with SH influenced by age, weight, gender, and blood pressure.20
Cross sectional studies have documented direct and indirect associ-
ations between increases in the aortic root size and increased blood
pressure.22 In one study, aortic dilatation at the sinuses of Valsalva
in people with SH was independently associated with left ventricu-
lar hypertrophy.5 In a more recent human study,6 the aortic diame-
ter was measured from the parasternal long-axis view at the level of
the sinus of Valsalva. In that study, aortic root dilatation was iden-
tified more in SH patients than normotensive patients without left
ventricular hypertrophy. These authors recommended that increased
aortic root diameter be considered evidence of target organ dam-
age. Increased risk of cardiovascular events has been documented
in people with SH and aortic dilatation regardless of left ventricular
hypertrophy or other comorbities.6 A study of over one million peo-
ple with SH found an increase in cardiovascular disease.32 In canine SH
patients, reported adverse cardiovascular complications include aortic
dilatation,2 dissecting aortic dissection, left sided heart failure, hyper-
tensive encephalopathy, cerebrovascular accidents, brain hemorrhage
or infarction, epistaxis, cognitive dysfunction,1,2 and abdominal aortic
dilatation/aneurysm.33 Earlier detection and treatment of SH by recog-
nition of asymmetric aortic cusps would hopefully prevent future car-
diovascular events.
In the study of 30 dogs with SH, none had left atrial enlargement
or an increase in the LA/Ao ratio.3 In contrast, left atrial diameter was
above the normal reference range in 96% of our SH dogs and the LA/Ao
was increased in 76% of dogs. This is consistent with previous feline
and canine case reports, and one study of cats with SH.10,13–15 In the
SH cat study, the left atrium was increased above the normal refer-
ence range (>15 mm) in 15 of 68 cats, the aortic root was increased
in only four of 67, and the LA/Ao ratio was increased (>1.6) in 19 of
67 cats.10 Although currently unrecognized in veterinary medicine, left
atrial enlargement alone is considered target organ damage in SH peo-
ple with mild valvular heart disease.24 In our study of 74 SH dogs, the
majority of the mitral valve regurgitation was recorded as trivial or mild
in 35 of 50 dogs (70%) and trivial or mild aortic insufficiency was seen in
eight of 21 (38%) making their left atrial enlargement potentially more
clinically significant.
A limitation of our study was that the dogs with normal blood
pressure presented with variable forms of cardiac disease with some
already receiving various cardiac medications. Our case selection was
limited because not all dogs have blood pressure measured when pre-
senting for cardiovascular workups. Just over 50% of the NBP dogs
did not receive any medications prior to their echocardiogram. Ideally,
only cases with dogs not receiving cardiac medications or in early stage
of heart disease would be included for assessment. However, no alter-
ations in the shape and size was identified when measuring each aortic
cusp in the dogs with normal blood pressure. A further limitation is that
the study was retrospective rather than prospective.
In human medicine, asymmetric aortic sinuses and aortic cusps
have been reported in SH patients and those with genetic disorders
resulting in development of thoracic aortic aneurysms.11 Although
not suspected in primarily older SH dogs, rare reports have identified
aortic root remodeling due to genetic conditions including familial
aortic aneurysm in a Leonberg puppy.35 Echocardiograms in cats with
mucopolysaccharidosis showed focal aortic root dilatation resulting
in an asymmetric appearance of the aortic cusps.36,37 A case report of
a Great Dane puppy presenting with pneumonia and a heart murmur
described notable dilatation of the ascending aorta on echocardiog-
raphy. Aortic dissection and rupture seen at necropsy were presumed
to be associated with a connective tissue disorder such as Marfan
syndrome.38
In conclusion, findings from the current study provided evidence
that asymmetrical size and shape of the aortic cusps is a reliable
HOLLAND ET AL .
echocardiographic indicator of SH in canine patients and may precede
concentric left ventricular hypertrophy, aortic aneurysm, or left-sided
heart failure.1 We propose that this form of aortic root dilatation and
left atrial dilatation with mild valvular insufficiency be included as tar-
get organ damage in SH canine patients. In our study, 43 of 74 (57%) of
SH dogs were prescribed medical management of their SH. Our hope
is that these findings will prompt earlier and sustained SH treatment
to prevent progressive target organ damage and future cardiovascular
events.
ACKNOWLEDGMENTS
Authors acknowledge Drs. Sara Bordelon, Seungwoo Jung, Randolph
Winter, and Daniel Newhard for image acquisitions that were used in
this study.
LIST OF AUTHOR CONTRIBUTIONS
Category 1
(a) Conception and Design: Holland, Hudson
(b) Acquisition of Data: Holland, Hudson
(c) Analysis and Interpretation of Data: Holland, Hofmeister,
Hudson
Category 2
(a) Drafting of Article: Holland, Hudson, Hofmeister
(b) Revising the Article for Intellectual Content: Holland, Hudson,
Hofmeister
Category 3
(a) Final Approval of the Completed Article: Holland, Hudson,
Hofmeister
CONFLICT OF INTEREST
The authors have no conflict of interest to declare.
ORCID
Merrilee Holland https://orcid.org/0000-0003-1359-4015
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How to cite this article: Holland M, Hofmeister E, Hudson J.
Echocardiographic changes in the shape and size of the aortic
cusps in dogs with confirmed systemic hypertension. Vet Radiol
Ultrasound. 2021;1-8. https://doi.org/10.1111/vru.13004