Pulmonic stenosis is a common congenital defect of dogs, and it most commonly involves fusion or dysplasia of the pulmonic valve leaflets (valvar or valvular). This condition affects a variety of dog breeds and is typically associated with a loud ejection murmur heard over the left base. Impedance to normal ejection and pressure overload of the right ventricle can result in right-side CHF, low-output signs (exercise intolerance, exertional syncope), and cardiac arrhythmias. Diagnosis can be made by echocardiography. Prognosis varies with severity of disease, and balloon valvuloplasty is typically recommended for moderate to severe cases.
Pulmonic stenosis is common in dogs and infrequent in cats. It results in obstruction to right ventricular outflow due, in most cases, to commissural fusion or dysplasia of the pulmonic valve with or without annular hypoplasia. Although the valvular form is most common, stenosis can also occur in the subvalvular region (infundibulum) or in the supravalvular area. Breed predilections for valvular pulmonic stenosis include:
English Bulldogs
Boxers
Beagles
Boykin Spaniels
French Bulldogs
Keeshonds
terriers
Pathophysiology of Pulmonic Stenosis in Animals
The right ventricle must generate increased pressure during systole to overcome the stenosis, which in more severe cases can lead to dramatic right ventricular concentric hypertrophy. As the right ventricle hypertrophies, ventricular compliance diminishes, leading to increased right atrial pressure and venous congestion. The turbulent jet of blood flow across the stenosis may deform the wall of the main pulmonary artery, resulting in a poststenotic dilatation. In severe cases, right-side congestive failure may be noted. Concurrent tricuspid valve dysplasia is sometimes noted in animals with pulmonic stenosis. Anomalous coronary artery development has been documented in some affected animals with pulmonic stenosis such as English Bulldogs and Boxers, and presence may affect treatment recommendations. Most commonly, the left main coronary artery originates from the right coronary artery and encircles the right ventricular outflow tract.
Clinical Findings of Pulmonic Stenosis in Animals
Courtesy of Dr. Sandra Tou.
Animals with pulmonic stenosis may have a history of exercise intolerance and failure to thrive. Right-side CHF may be present and is characterized by ascites and less commonly peripheral edema. A prominent systolic ejection murmur is present and heard loudest over the pulmonic valve area (left base). A corresponding precordial thrill may be present. Jugular distention and pulsations may also be present.
Electrocardiography will demonstrate evidence of right ventricular enlargement (deep S waves in lead II) in many cases. Radiographic abnormalities include right ventricular enlargement, dilatation of the main pulmonary artery, and diminished pulmonary perfusion.
Echocardiography is indicated to obtain a definitive diagnosis and may demonstrate right ventricular hypertrophy and dilatation, fused or thickened and relatively immobile pulmonic valve cusps, and turbulent blood flow across the stenosis. In a few cases, supravalvular or discrete subvalvular stenosis can be noted.
Pulmonic insufficiency can be seen in dogs with pulmonic stenosis. The velocity of blood flow across the stenosis is measured by echocardiography and used to assess the severity of disease.
Treatment of Pulmonic Stenosis in Animals
Moderate or severe cases can be treated with balloon valvuloplasty or surgery.
Animals with moderate or severe pulmonic stenosis can benefit from balloon valvuloplasty or surgical intervention (valvulotomy, patch grafting, partial valvulectomy, or conduits). Balloon valvuloplasty is a minimally invasive and highly effective treatment option. Some animals are medically managed with a beta-blocker (eg, atenolol) alone or in conjunction with balloon valvuloplasty. Congestive heart failure should be medically managed if present. Similarly, the presence of supraventricular or ventricular arrhythmias warrants therapy with the appropriate antiarrhythmic drug(s).
Key Points
Pulmonic stenosis most commonly occurs due to commissural fusion or dysplasia of valve leaflets and occurs in a variety of breeds, including the English Bulldog.
A loud, systolic ejection murmur is typically heard over the left base of the heart.
Definitive diagnosis can be achieved by echocardiography, and balloon valvuloplasty should be considered in moderate to severe cases.
