![]() ![]() (A) Right ventriculogram demonstrating a filling defect at the level of the pulmonary valve and subvalvar regions consistent with severe pulmonary valve and subvalvar dysplasia. Pimobendan was started at 5 mg orally every 12 hours because of right ventricular systolic dysfunction, and atenolol was decreased to 12.5 mg orally every 12 hours.įigure 2 Fluoroscopic and angiographic imaging from initial cardiac catheterization (A- C) and during stent implantation (D- F). The animal recovered from anesthesia uneventfully. BPV was not performed, because of risk for damage to the anomalous coronary artery. Simultaneous aortic root and right ventricular injections further confirmed the single left coronary ostium and anomalous prepulmonary course of the RCA ( Video 6). A forme fruste of patent ductus arteriosus was also present incidentally. The anomalous RCA displayed a prepulmonary course. An aortic root injection using a 5-F, 100-cm pigtail catheter (Merit Medical, South Jordan, UT) confirmed a single left coronary ostium with an anomalous right coronary artery (RCA) arising from the left paraconal branch ( Figures 2B and 2C, Videos 4 and 5). Vascular access to the right femoral artery was performed using a 5-F, 10-cm introducer (Introducer set). The levo-phase raised suspicion for a single left coronary ostium. Severe post-stenotic dilatation of the pulmonary trunk and branch pulmonary arteries, severe concentric and eccentric right ventricular hypertrophy, and subjective right ventricular systolic dysfunction were present. Right ventriculography was performed (Berman angiographic catheter Optiray 741 mg I/mL ), demonstrating severe pulmonary valve and subvalvar dysplasia ( Figure 2A, Video 3). A pressure pull-back (Berman angiographic catheter Arrow International, Morrisville, NC) from the pulmonary trunk to the right ventricle revealed a pressure gradient of 53 mm Hg. Right heart catheterization was performed after placing a 6-Fr, 6-cm introducer (Introducer set, Terumo Medical, Somerset, NJ) and upsizing to an 11-F, 10-cm introducer (Introducer set) in the right femoral vein. Anesthesia was maintained with isoflurane in 100% oxygen, with constant-rate infusions of fentanyl and lidocaine. The following month, the dog was premedicated with methadone and alfaxalone intramuscularly and preoxygenated, and anesthesia was induced with midazolam and propofol intravenously. ![]() Right heart catheterization, cardiac angiography, and high-pressure balloon valvuloplasty were initially recommended, and informed consent was obtained from the owner. Atenolol was prescribed, titrating to a maintenance dose of 25 mg orally every 12 hours. Concurrent electrocardiography during echocardiography revealed sinus rhythm with occasional ventricular premature complexes, likely of right-sided origin. A right coronary ostium could not be definitively identified. Evaluation of the aortic root demonstrated a prominent left coronary ostium arising off of the left coronary cusp ( Video 2). A right-to-left shunting patent foramen ovale was noted. Subjectively severe right ventricular concentric and moderate eccentric hypertrophy were present, with prominent septal flattening throughout the cardiac cycle. The peak transpulmonary systolic pressure gradient was 113 mm Hg, consistent with severe pulmonary valve and subvalvar dysplasia ( Figure 1B). Color flow Doppler investigation identified flow acceleration beginning at the subvalvar ridge, as well as moderate pulmonary valve insufficiency. Transthoracic two-dimensional and Doppler echocardiography (iE33, Philips Medical Systems, Andover, MA) was performed and revealed a severely dysplastic pulmonary valve in addition to a discrete ridge of tissue immediately subvalvar to the pulmonary annulus ( Figure 1A, Video 1). Systolic blood pressure was considered normal at 140 mm Hg. His lung sounds were normal, and femoral pulses were strong and synchronous. Physical examination revealed a grade IV/VI left basilar systolic heart murmur, a normal heart rate of 80 beats/min, and a regular rhythm. He was adopted 3 months before presentation and was reported to have increased respiratory effort and exercise intolerance. A 3-year-old male intact English bulldog weighing 22.4 kg was presented for evaluation of a heart murmur before general anesthesia and neutering. ![]()
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