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Brown C, Stefaniuk-Szmukier M, Decloedt A, Beijerink N, Hamilton NA, Velie BD. Congenital heart defects in Arabian horses and the prospects of genetic testing: A review. Equine Vet J 2024. [PMID: 38272847 DOI: 10.1111/evj.14062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 01/04/2024] [Indexed: 01/27/2024]
Abstract
Congenital heart defects (CHDs) can have profound and potentially life-threatening consequences on horses' health and performance capability. While CHDs are rare in the general horse population, the Arabian breed is disproportionately overrepresented and thus is widely suspected to be genetically predisposed. This review discusses the most common CHDs in Arabian horses, including ventricular septal defect (VSD), tetralogy of Fallot (TOF), patent duct arteriosus (PDA), tricuspid valve atresia (TVA) and atrial septal defect (ASD). This review also explores how future research into the genetic factors that likely underpin many CHDs can revolutionise the way these disorders are managed in Arabian horses.
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Affiliation(s)
- Caitlin Brown
- Equine Genetics and Genomics Group, School of Life and Environmental Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Monika Stefaniuk-Szmukier
- Department of Animal Molecular Biology, National Research Institute of Animal Production, Balice, Poland
| | - Annelies Decloedt
- Equine Cardioteam Ghent, Department of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Niek Beijerink
- Veterinaire Specialisten Vught, Vught, The Netherlands
- Sydney School of Veterinary Science, Faculty of Science, University of Sydney, Sydney, New South Wales, Australia
| | - Natasha A Hamilton
- Sydney School of Veterinary Science, Faculty of Science, University of Sydney, Sydney, New South Wales, Australia
| | - Brandon D Velie
- Equine Genetics and Genomics Group, School of Life and Environmental Sciences, University of Sydney, Sydney, New South Wales, Australia
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Reference Values and Repeatability of Pulsed Wave Doppler Echocardiography Parameters in Normal Donkeys. Animals (Basel) 2022; 12:ani12172296. [PMID: 36078016 PMCID: PMC9454746 DOI: 10.3390/ani12172296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/25/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Cardiovascular disease is underreported in donkeys, possibly related to their limited athletic posture and frequent poor performance-related examinations. Reports on treatments for cardiovascular disease are anecdotal in donkey. Normal echocardiographic parameters have been reported in healthy donkeys. The aim of the present study was to establish the reference values and repeatability for Pulsed Wave Doppler echocardiographic variables of the mitral valve, aortic valve and myocardial performance. Two-dimensional Color flow mapping and spectral Doppler modes were performed. For the mitral valve, the mean velocity, pressure gradient and duration of E-wave were 57.7 ± 12.5 cm/s, 1.4 ± 0.7 mmHg and 0.4 ± 0.13 s, respectively. The results of the present study provide the reference values of PW echocardiographic parameters measurements in normal adult donkeys. Such reference values are helpful, especially when confronted with clinical cases with cardiovascular disorders. Abstract In the present study, thirty clinically healthy donkeys were used to establish the reference values and repeatability for Pulsed Wave Doppler echocardiographic variables of the mitral valve, aortic valve and myocardial performance. 2-dimensional Color flow mapping and spectral Doppler modes were performed. For the mitral valve, the mean velocity, pressure gradient and duration of E-wave were 57.7 ± 12.5 cm/s, 1.4 ± 0.7 mmHg and 0.4 ± 0.13 s, respectively. The velocity, pressure gradient and duration of the A-wave were 32.3 ± 9.1 cm/s, 0.3 ± 0.04 mmHg and 0.3 ± 0.1 s, respectively. The mitral valve area, pressure half time, pulsatility index (PI), resistance index (RI) and velocity time integral (VTI) were 1.8 ± 0.5 cm2, 66 ± 17 ms, 2.8 ± 1.4, 0.9 ± 0.03 and 19.1 ± 5.7 cm, respectively. For the aortic valve, the mean velocity was 64.9 ± 10.4 cm/s, pressure gradient was 1.8 ± 0.4 mmHg, pulsatility index was 1.4 ± 0.3, resistance index was 0.9 ± 0.02, VTI was 25.02 ± 6.2 cm, systolic/diastolic was 19 ± 4.7 and heart rate was 95.7 ± 28.9 per minute. For Myocardial Performance Index (LV)–Tei Index, the mean ejection, isovolumic relaxation, isovolumic contraction time and myocardial performance index were 0.24 ± 0.01, 0.14 ± 0.01, 0.14 ± 0.02 and 1.2 ± 0.1 s, respectively. The results of the present study provide the reference values of PW echocardiographic parameter measurements in normal adult donkeys. Such reference values are helpful, especially when confronted with clinical cases with cardiovascular disorders.
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Echocardiographic Features of the Ductus Arteriosus and the Foramen Ovale in a Hospital-Based Population of Neonatal Foals. Animals (Basel) 2022; 12:ani12172242. [PMID: 36077962 PMCID: PMC9454784 DOI: 10.3390/ani12172242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/21/2022] [Accepted: 08/26/2022] [Indexed: 11/28/2022] Open
Abstract
Simple Summary In fetal circulation, the distribution of oxygenated blood from the maternal placenta is facilitated by two intracardiac shunts. Oxygenated blood flows from the right atrium to the left heart through the foramen ovale, which is formed by the septum primum and septum secundum. Less oxygenated blood is directed to the placenta through the ductus arteriosus, which connects the pulmonary artery and the aorta. The ductus arteriosus and foramen ovale should close after birth. However, knowledge about the exact time of closure of those structures in foals is limited. The current study investigates the ultrasonographical closure of both the ductus arteriosus and the foramen ovale in healthy and diseased neonatal foals. Cardiac auscultation and ultrasound were performed on fifty foals. Cardiac murmurs were common, and in some foals, the ductus arteriosus was still open at ten days of age. The foramen ovale was not open; however, a fluttering motion of the septum primum into the left atrium was a common finding in healthy and diseased foals. The exact clinical importance of those findings needs to be further elucidated. Abstract The ductus arteriosus (DA) and foramen ovale (FO), including the septum primum (SP) and septum secundum (SS), are important structures in fetal circulation and are unexplored in neonatal equids. The objective of this study is to describe echocardiographic characteristics in a hospital-based population of neonatal foals. On days 2, 5 and 10 after parturition, cardiac ultrasound was performed, and clinical data were collected in healthy and diseased Warmblood foals. Fifty healthy (n = 15) and diseased (n = 35) Warmblood foals were examined. A left-sided and right-sided holosystolic murmur was audible in 98% (n = 42) and 51% (n = 22), respectively, on day 2; in 81% (n = 25) and 19% (n = 6) on day 5; and in 44% (n = 4) and 11% (n = 1) on day 10. The median grade of the systolic murmurs was higher when the DA was open. Flow through the DA could be visualized with color flow and continuous wave (CW) Doppler from the left parasternal long-axis view of the pulmonary artery in 40/43 foals on day 2, 9/31 foals on day 5 and 2/9 foals on day 10. The DA diameter was 2 ± 1 mm on day 2, 2 ± 1 mm on day 5 and 1 mm on day 10. The thickness of both septa of the FO was similar. The SP fluttered into the left atrium at all ages, but the maximal distance between the SP and SS decreased over time. In conclusion, cardiac murmurs, a patent DA and fluttering FO are frequent findings in neonatal foals. While these findings are probably physiological, the clinical importance needs to be further elucidated.
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Fernández‐Parra R, Losada‐Floriano A, Zilberstein L, Bourzac C. Iatrogenic pneumothorax‐induced heart murmur during standing laparoscopy in a 3‐year‐old horse. EQUINE VET EDUC 2022. [DOI: 10.1111/eve.13641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- R. Fernández‐Parra
- Pôle Anesthésie et Réanimation Urgences et Soins Intensifs Ecole Nationale Vétérinaire d'Alfort Maisons‐Alfort France
- Department of Small Animal Medicine and Surgery Faculty of Veterinary Medicine Catholic University of Valencia ‘San Vicente Mártir’ Valencia Spain
| | - A. Losada‐Floriano
- Clinique Equine Ecole Nationale Vétérinaire d'Alfort Maisons‐Alfort France
| | - L. Zilberstein
- Pôle Anesthésie et Réanimation Urgences et Soins Intensifs Ecole Nationale Vétérinaire d'Alfort Maisons‐Alfort France
| | - C. Bourzac
- Clinique Equine Ecole Nationale Vétérinaire d'Alfort Maisons‐Alfort France
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Woort F, Reef V, Stefanovski D, Slack J. Cardiac pre‐purchase examination in horses – evaluation, outcome and athletic follow‐up. EQUINE VET EDUC 2021. [DOI: 10.1111/eve.13507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- F. Woort
- Equine Sports Medicine Practice Waterloo Belgium
| | - V. Reef
- New Bolton Center University of Pennsylvania Kennett Square Pennsylvania USA
| | - D. Stefanovski
- New Bolton Center University of Pennsylvania Kennett Square Pennsylvania USA
| | - J. Slack
- New Bolton Center University of Pennsylvania Kennett Square Pennsylvania USA
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De Lange L, Vera L, Decloedt A, Van Steenkiste G, Vernemmen I, van Loon G. Prevalence and characteristics of ventricular septal defects in a non-racehorse equine population (2008-2019). J Vet Intern Med 2021; 35:1573-1581. [PMID: 33742468 PMCID: PMC8163134 DOI: 10.1111/jvim.16106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 11/29/2022] Open
Abstract
Background Ventricular septal defects (VSDs) are the most common congenital cardiac defect in horses. Objectives To identify prevalence, age, breed, and sex distribution of VSD and to describe associated clinical and ultrasonographic findings. Animals Hospital‐based population of 21 136 horses presented to the equine internal medicine department. Methods Medical records over a 12‐year period were reviewed for VSD confirmed by ultrasonography. Age, breed, sex, sport discipline, murmur, clinical signs, outcome, VSD type, VSD size, shunt velocity, cardiac dimensions, concomitant cardiac anomalies, and valvular regurgitations were recorded. Results From 1894 horses that underwent echocardiography, 54 had a VSD: 42 as an isolated lesion and 12 as part of complex congenital heart disease (CHD). Median age was 5 years (range, 0‐26) and 1 year (range, 0‐8), respectively. Warmbloods and males were overrepresented. In the isolated VSD group, only 15% had associated clinical signs and most horses had a perimembranous VSD (pmVSD; 36/42). Horses with a pmVSD and clinical signs showed a significantly lower maximal shunt velocity (3.77 vs 5.20 m/s; P < .001), higher VSD/Aortic root (Ao) diameter (0.52 vs 0.38; P = .05), higher left atrium/Ao diameter (1.94 vs 1.22; P < .001), and higher pulmonary artery/Ao diameter (1.15 vs 0.88; P = .005) compared to horses without clinical signs. All horses with complex CHD had clinical signs and abnormal cardiac dimensions. Conclusion and Clinical Importance Most isolated VSD were diagnosed only at a later age and were not associated with clinical signs. Horses with complex CHD were more likely to have or develop clinical signs at younger age.
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Affiliation(s)
- Lisa De Lange
- Equine Cardioteam, Department of Large Animal Internal Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Lisse Vera
- Equine Cardioteam, Department of Large Animal Internal Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Annelies Decloedt
- Equine Cardioteam, Department of Large Animal Internal Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Glenn Van Steenkiste
- Equine Cardioteam, Department of Large Animal Internal Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Ingrid Vernemmen
- Equine Cardioteam, Department of Large Animal Internal Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Gunther van Loon
- Equine Cardioteam, Department of Large Animal Internal Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
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Zuber N, Zuber M, Schwarzwald CC. Assessment of systolic and diastolic function in clinically healthy horses using ambulatory acoustic cardiography. Equine Vet J 2018; 51:391-400. [DOI: 10.1111/evj.13014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 08/21/2018] [Indexed: 12/13/2022]
Affiliation(s)
- N. Zuber
- Clinic for Equine Internal Medicine, Vetsuisse Faculty University of Zurich Zurich Switzerland
| | - M. Zuber
- Division of Cardiology University of Zurich Zurich Switzerland
| | - C. C. Schwarzwald
- Clinic for Equine Internal Medicine, Vetsuisse Faculty University of Zurich Zurich Switzerland
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Mitchell KJ, Schwarzwald CC. Echocardiography for the Assessment of Congenital Heart Defects in Calves. Vet Clin North Am Food Anim Pract 2016; 32:37-54. [DOI: 10.1016/j.cvfa.2015.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Michlik KM, Biazik AK, Henklewski RZ, Szmigielska MA, Nicpoń JM, Pasławska U. Quadricuspid aortic valve and a ventricular septal defect in a horse. BMC Vet Res 2014; 10:142. [PMID: 24981768 PMCID: PMC4134333 DOI: 10.1186/1746-6148-10-142] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 06/17/2014] [Indexed: 12/13/2022] Open
Abstract
Background Quadricuspid aortic valve (QAV) and ventricular septal defect (VSD) are congenital heart defects and have been described in both human and veterinary medical literature. Case presentation A 5-year-old half-bred bay stallion was referred for surgical castration. Cardiac murmurs were heard on the presurgical clinical examination and the cardiac examination revealed subcutaneous oedema, tachycardia with a precodrial thrill and a grade 5/6 pansystolic murmur, which was heard on auscultation of the right and left side of the chest. Examination of the B-mode echocardiograms revealed the presence of a QAV (one small cusp, two equal-sized cusps, and one large cusp) and VSD in the membranous portion of the intraventricular septum. These two congenital cardiac defects were accompanied by mild aortic valve regurgitation and severe tricuspid regurgitation. Despite the presence of these cardiac defects, the horse underwent surgical castration under general anesthesia. Surgery, anaesthesia and recovery from anaesthesia were uneventful. The gelding was euthanasied after 17 months because of a progressive loss of body weight, weakness and recumbency. Conclusion A QAV in combination with VSD in a horse is an interesting finding, because to the best of our knowledge, this has not been previously described in equine literature.
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Affiliation(s)
- Katarzyna M Michlik
- Department of Internal Medicine and Clinic of Disease of Horses, Dogs and Cats, Veterinary Faculty of Wrocław University of Environmental and Life Sciences, pl, Grunwaldzki 47, 50-366 Wrocław, Poland.
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Reef VB, Bonagura J, Buhl R, McGurrin MKJ, Schwarzwald CC, van Loon G, Young LE. Recommendations for management of equine athletes with cardiovascular abnormalities. J Vet Intern Med 2014; 28:749-61. [PMID: 24628586 PMCID: PMC4895474 DOI: 10.1111/jvim.12340] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 01/28/2014] [Accepted: 01/28/2014] [Indexed: 11/29/2022] Open
Abstract
Murmurs and arrhythmias are commonly detected in equine athletes. Assessing the relevance of these cardiovascular abnormalities in the performance horse can be challenging. Determining the impact of a cardiovascular disorder on performance, life expectancy, horse and rider or driver safety relative to the owner's future expectations is paramount. A comprehensive assessment of the cardiovascular abnormality detected is essential to determine its severity and achieve these aims. This consensus statement presents a general approach to the assessment of cardiovascular abnormalities, followed by a discussion of the common murmurs and arrhythmias. The description, diagnosis, evaluation, and prognosis are considered for each cardiovascular abnormality. The recommendations presented herein are based on available literature and a consensus of the panelists. While the majority of horses with cardiovascular abnormalities have a useful performance life, periodic reexaminations are indicated for those with clinically relevant cardiovascular disease. Horses with pulmonary hypertension, CHF, or complex ventricular arrhythmias should not be ridden or driven.
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Affiliation(s)
- V B Reef
- Department of Clinical Studies-New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Kennett Square, PA
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Hallowell GD, Bowen M. Reliability and identification of aortic valve prolapse in the horse. BMC Vet Res 2013; 9:9. [PMID: 23311963 PMCID: PMC3547808 DOI: 10.1186/1746-6148-9-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 01/08/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objectives were to determine and assess the reliability of criteria for identification of aortic valve prolapse (AVP) using echocardiography in the horse. RESULTS Opinion of equine cardiologists indicated that a long-axis view of the aortic valve (AoV) was most commonly used for identification of AVP (46%; n=13). There was consensus that AVP could be mimicked by ultrasound probe malignment. This was confirmed in 7 healthy horses, where the appearance of AVP could be induced by malalignment. In a study of a further 8 healthy horses (5 with AVP) examined daily for 5 days, by two echocardiographers standardized imaging guidelines gave good to excellent agreement for the assessment of AVP (kappa>0.80) and good agreement between days and observers (kappa >0.6). The technique allowed for assessment of the degree of prolapse and measurement of the prolapse distance that provided excellent agreement between echocardiographers, days and observers (kappa/ICC>0.8). Assessments made using real-time zoomed images provided similar measurements to the standard views (ICC=0.9), with agreement for the identification of AVP (kappa>0.8). Short axis views of the AoV were used for identification of AVP by fewer respondents (23%), however provided less agreement for the identification of AVP (kappa>0.6) and only adequate agreement with observations made in long axis (kappa>0.5), with AVP being identified more often in short axis (92%) compared to long axis (76%). Orthogonal views were used by 31% of respondents to identify the presence of AVP, and 85% to identify cusp. Its identification on both views on 4 days was used to categorise horses as having AVP, providing a positive predictive value of 79% and negative predictive value of 18%. Only the non-coronary cusp (NCC) of the AoV was observed to prolapse in these studies. Prolapse of the NCC was confirmed during the optimisation study using four-dimensional echocardiography, which concurred with the findings of two-dimensional echocardiography. CONCLUSIONS This study has demonstrated reliable diagnostic criteria for the identification and assessment of AVP that can be used for longitudinal research studies to better define the prevalence and natural history of this condition.
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Affiliation(s)
- Gayle D Hallowell
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Sutton Bonington, Leicestershire, UK.
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ZUCCA E, FERRUCCI F, STANCARI G, SAPORITI T, FERRO E. The Prevalence of Cardiac Murmurs among Standardbred Racehorses Presented with Poor Performance. J Vet Med Sci 2010; 72:781-5. [DOI: 10.1292/jvms.09-0217] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Enrica ZUCCA
- Department of Veterinary Clinical Sciences, Equine Internal Medicine and Sports Medicine Service, Large Animal Veterinary Hospital, University of Milan
| | - Francesco FERRUCCI
- Department of Veterinary Clinical Sciences, Equine Internal Medicine and Sports Medicine Service, Large Animal Veterinary Hospital, University of Milan
| | - Giovanni STANCARI
- Department of Veterinary Clinical Sciences, Equine Internal Medicine and Sports Medicine Service, Large Animal Veterinary Hospital, University of Milan
| | - Tiziana SAPORITI
- Department of Veterinary Clinical Sciences, Equine Internal Medicine and Sports Medicine Service, Large Animal Veterinary Hospital, University of Milan
| | - Elisabetta FERRO
- Department of Veterinary Clinical Sciences, Equine Internal Medicine and Sports Medicine Service, Large Animal Veterinary Hospital, University of Milan
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Davis JL, Gardner SY, Schwabenton B, Breuhaus BA. Congestive heart failure in horses: 14 cases (1984-2001). J Am Vet Med Assoc 2002; 220:1512-5. [PMID: 12018380 DOI: 10.2460/javma.2002.220.1512] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To identify clinical signs, underlying cardiac conditions, echocardiographic findings, and prognosis for horses with congestive heart failure. DESIGN Retrospective study. ANIMALS 14 horses. PROCEDURE Signalment; history; clinical signs; clinicopathologic, echocardiographic, and radiographic findings; treatment; and outcome were determined by reviewing medical records. RESULTS All 14 horses were examined because of a heart murmur; tachycardia was identified in all 14. Twelve horses had echocardiographic evidence of enlargement of 1 or more chambers of the heart. Other common clinical findings included jugular distention or pulsation, crackles, cough, tachypnea, and ventral edema. Nine horses had signs consistent with heart failure for > 6 days. Underlying causes for heart failure included congenital defects, traumatic vascular rupture, pericarditis, pulmonary hypertension secondary to heaves, and valvular dysplasia. Seven horses were euthanatized after diagnosis of heart failure; 5 were discharged but were euthanatized or died of complications of heart disease within 1 year after discharge. The remaining 2 horses were discharged but lost to follow-up. CONCLUSIONS AND CLINICAL RELEVANCE Results suggest that congestive heart failure is rare in horses. A loud heart murmur accompanied by either jugular distention or pulsation, tachycardia, respiratory abnormalities (crackles, cough, tachypnea), and ventral edema were the most common clinical signs. Echocardiography was useful in determining the underlying cause in affected horses. The long-term prognosis for horses with congestive heart failure was grave.
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Affiliation(s)
- Jennifer L Davis
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh 27606, USA
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