Tracheal hypoplasia with a discrete subaortic septal ridge in a Rottweiler puppy

Discrete Subaortic Stenosis: Perspective Roadmap to a Complex Disease

Discrete subaortic stenosis (DSS) is a congenital heart disease that results in the formation of a fibro-membranous tissue, causing an increased pressure gradient in the left ventricular outflow tract (LVOT). While surgical resection of the membrane has shown some success in eliminating the obstruction, it poses significant risks associated with anesthesia, sternotomy, and heart bypass, and it remains associated with a high rate of recurrence. Although a genetic etiology had been initially proposed, the association between DSS and left ventricle (LV) geometrical abnormalities has provided more support to a hemodynamic etiology by which congenital or post-surgical LVOT geometric derangements could generate abnormal shear forces on the septal wall, triggering in turn a fibrotic response. Validating this hypothetical etiology and understanding the mechanobiological processes by which altered shear forces induce fibrosis in the LVOT are major knowledge gaps. This perspective paper describes the current state of knowledge of DSS, articulates the research needs to yield mechanistic insights into a significant pathologic process that is poorly understood, and proposes several strategies aimed at elucidating the potential mechanobiological synergies responsible for DSS pathogenesis. The proposed roadmap has the potential to improve DSS management by identifying early targets for prevention of the fibrotic lesion, and may also prove beneficial in other fibrotic cardiovascular diseases associated with altered flow.

Comparison between tracheal ratio methods used by three observers at three occasions in English Bulldogs

BACKGROUND

Tracheal hypoplasia is a congenital condition described in mainly brachycephalic breeds and is one component of the brachycephalic obstructive airway syndrome (BOAS). Two radiographic methods have been described to evaluate the dimensions of the tracheal diameter in dogs and to distinguish between hypoplastic and non-hypoplastic tracheas: the tracheal lumen diameter to thoracic inlet distance ratio (TD/TI) and the ratio between the thoracic tracheal luminal diameter and the width of the proximal third of the third rib (TT/3R). The purpose of this study was to compare these two published radiographic methods between observers, different measuring occasions and to investigate the effect on classification of dogs as having hypoplastic or non-hypoplastic tracheas using four previously published mean ratios as cut-offs (<0.11, <0.127 and <0.144 for the TD/TI and <2.0 for the TT/3R method). Three observers evaluated right and left lateral recumbent radiographs from 56 adult English Bulldogs independently on three different occasions. TD/TI and TT/3R ratios were calculated and correlated between measuring occasions. Kappa, observed, positive, and negative agreements were calculated between observers and measuring occasions. Number of hypoplastic and non-hypoplastic dogs for each method and occasion was determined using <0.11, <0.127 and <0.144 as cut-offs for TD/TI and <2.0 for TT/3R.

RESULTS

Intraobserver agreement varied with kappa between 0.45-0.94 for the TD/TI and 0.20-0.86 for the TT/3R method. Interobserver kappa varied between 0.27-0.70 for the TD/TI method and between 0.05-0.57 for the TT/3R method. There was poor agreement in classifying English Bulldogs as tracheal hypoplastic or non-hypoplastic, depending on measuring method, cut-off value and observer.

CONCLUSIONS

The diagnostic value of both the TD/TI and TT/3R methods with such poor agreement is questionable, and significantly impacts their reliability for both clinical evaluation of dogs and use in health screening programs.