Veterinary cardiologist Dr. Anna Mac joins us to discuss the case of Baguette, a 2 year-old english bulldog with brachycephalic airway disease and pulmonic stenosis. Dr. Mac covers the diagnostic workup, treatment options and likely outcomes. This is a common condition in a common breed… and you won’t want to miss this episode!
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LINKS
Purdue University College of Veterinary Medicine: vet.purdue.edu/
Dr. Andy Roark Exam Room Communication Tool Box Course: drandyroark.com/on-demand-staff-training/
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Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Dr. McManamey (aka Dr. Mac) is a veterinary cardiologist. She received her degree of veterinary medicine from the University of Missouri. She then completed a rotating internship at the Ohio State University followed by an emergency and critical care internship at North Carolina State University. She finished her cardiology residency at North Carolina State University and became an ACVIM diplomate in 2021. Dr. Mac is currently an assistant clinical professor at Purdue University in Indiana. Cardiology is her favorite subject because it can be made as simple or as complex as needed. Furthermore, every animal has a heart and that means Dr. Mac gets to work with all kinds of species. Her areas of interest within cardiology are echocardiogram, congenital heart disease and interventional procedures, as well as emergency management of cardiac disease. She has a very supportive and patient husband along with three canine fur-children, one of which had a patent ductus arteriosus (of course).
EPISODE TRANSCRIPT
This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.
Dr. Andy Roark:
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Dr. Andy Roark:
Welcome, everybody, to the Cone Of Shame veterinary podcast. I am your host, Dr. Andy Roark. Guys, I have a great episode for you today with my friend, cardiologist and rising legend, Dr. Anna McManame or Dr. Mac, as she is known at Purdue, where she is an assistant clinical professor. Gosh, she’s awesome. She is such an excellent teacher. I met her just by chance early this year. This is her third episode of the Cone Of Shame and I can’t get enough of her. She is so matter-of-fact, and to the point and just a good teacher. She just reigns pearls of wisdom down on me as I ask her these questions, and I am a better doctor having talked to her.
Dr. Andy Roark:
Guys, today, we are talking about a young bulldog who comes in to have brachycephalic airway surgery and that’s when we find the heart murmur. Ultimately, we end up talking about pulmonic stenosis in the bulldogs. Super fascinating conversation, really interesting. Man, bunch of stuff I’m going to be looking out for in the future that I’m not looking out for in the past. You learn. You know better and you do better. That’s what medicine is. Guys, you’re going to love this. Let’s get into it.
Kelsey Beth Carpenter:
(Singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone Of Shame with Dr. Andy Roark.
Dr. Andy Roark:
Welcome to the podcast, Dr. Anna McManame. How are you?
Dr. Anna McManamey:
I’m good. How are you, Andy?
Dr. Andy Roark:
I’m so great. Thanks for being back. This is your third time’s on-
Dr. Anna McManamey:
It’s been fun. Yeah.
Dr. Andy Roark:
… on the podcast. Well, you have been a very popular guest in the past, as I looked at our YouTube. As we’re recording this, your video with me came out less than a week ago, and it’s got like 100 and something views already. That’s pretty good since we just started doing YouTube. You’re doing good stuff. You’re fun to talk to so thanks for being here.
Dr. Anna McManamey:
Thanks for having me.
Dr. Andy Roark:
Man, always. I’m just going to apologize right ahead of time. I might not be at my best today because I’m going through some stuff and this is going to be hard to hear but my wife used the last of the almond milk that I was planning on for my smoothie. She didn’t say anything. She just left.
Dr. Anna McManamey:
She just left.
Dr. Andy Roark:
She just left. I found a recycling bin. I was like time for my smoothie and it wasn’t there, and so my world is kind of on fire. My love is to lie. It is what take away. I just want to apologize for that. While I get over my feelings of loss and contemplate a smoothie with tap water, like a peasant would have. Yeah, exactly. Anyway, I have a case that I would like to change the topic to, and talk to you about. Are you ready for it?
Dr. Anna McManamey:
I’m ready.
Dr. Andy Roark:
All right. Cool. I have a bulldog, a little-ish bulldog. She’s about two years of age. Her name is Baguette, which is a fun bulldog name. Baguette, the two-year-old bulldog. Her face kind of looks like a baguette. I guess kind of a squish, maybe a croissant face.
Dr. Anna McManamey:
Is she a French bulldog?
Dr. Andy Roark:
She’s not. She’s an English bulldog, which is really… Someone missed a trick there. She’s in for a stenotic airway surgery. Her little nostrils are just completely pinched closed. She’s about years and this was recommended. She has come in, and we’re getting ready for the surgery. I’m sculpting a heart murmur on this two-year-old dog. She seems asymptomatic. She’s bouncing around. There’s no coughing. There’s no nothing. I just wanted to go ahead and pull this out for you and sort of say, what are your thoughts when I’m looking at this little brachycephalic dog that’s got a heart murmur. Are those things related? Is this something I need to be worried about? What kind of monitoring should be looking at? Just start to unpack for me, how do you treat that?
Dr. Anna McManamey:
Yeah. I would say that we actually see this scenario, not uncommonly. Some of these dogs, maybe they’ll even have a clinical sign of “exercise intolerance”. They get out of breath quickly. The most logical thing is it’s their airway because these breeds-
Dr. Andy Roark:
Yeah, because she can’t breathe. I would 100% be like, I know what I got. Ding, ding, I know what this is.
Dr. Anna McManamey:
Got it. Done. On really close examination, once they’re either sedated, pre-anesthetically or they just stopped wiggling, someone hears a murmur. I usually have a rule that if I ever have someone that says, “I hear murmur in a dog younger than about three to five,” I keep inching my ears up because sometimes we’re not catching these congenital murmurs as early, but I’d say solidly if the patient’s less than three years of age and the murmur is a three or more, I consider that likely congenital heart disease that warrants further evaluation.
Dr. Anna McManamey:
I’ll say with bulldog, their anatomy just doesn’t lend itself nicely towards clean auscultation. Some murmurs are really hard to hear. You can’t tell over their referred airway noise, they’re snorting or their chest confirmation that you can’t hear the noise loud enough. Any time, I have a brachycephalic that’s a bulldog in particular, or any of these pity terriers that are now getting more and more bully-like. My top differential’s pulmonic stenosis in those dogs. We’re seeing it happen so commonly that even if they’re asymptomatic or we think they’re asymptomatic and I hear murmur that’s louder than a three, it’s a young dog, I’d be worried about pulmonic stenosis. That murmur is usually on the left side of the chest, but can radiate to the right side of the chest. I would recommend a further workout before anesthetizing that dog.
Dr. Andy Roark:
Okay, cool. Let’s start to unpack what that workout looks like in general practice. I agree with that. I would say to the owners, “Hey, I’m a bit concerned about this.” They’ve been great. They’re here for airway surgery. They’re invested in the pet. I’m happy to talk to them about taking a closer look. What does that look like in your mind?
Dr. Anna McManamey:
Yeah. One of the things that, I think not many people think to do, but something that I actually recommend doing is if you have even just a lead to ECG. Just an ECG machine that you would use for an anesthetic patient, it doesn’t have to be diagnostic. Doesn’t have be anything fancy but if you have that ECG lead, I’m looking for access deviations. I expect a sinus rhythm, so P, Q, R, S and T, but dogs with significant right heart remodeling, we can see that the QRS complex, it looks inverted, so they have a really deep S wave, even in lead two. It tells us that more of their electrical energy is actually going towards the right side of their heart rather than the left side. That can sometimes be a nice tip-off that they might have right side of the margin.
Dr. Anna McManamey:
Now, there definitely can be false negatives. It’s just something that’s relatively cheap and usually, if you’re there contemplating anesthesia, you have the equipment anyway. Something that’s relatively cheap, doesn’t cause any invasive procedures at all. It’s something I’d consider. I think that doing chest x-rays has its place, but sometimes can be not really any superior than just sending them straight for echo. If you’ve got a client where they’re not really convinced that they want to move forward with a cardiology assessment, with an echocardiogram, you could offer baseline chest radiographs. The purpose is to try and see, is there severe cardiac enlargement? If we’re looking for pulmonic stenosis, it’s going to be right-sided enlargement. This is going to be a widened cardiac silhouette on the lateral views. It’s going to be a loss of a cranial waste. Then on the dose eventual projection, we’re going to look for a big MPA bulge. There’s a big bulge that we see over there, but nothing is going to surpass the ability of an echocardiogram to really diagnose the cause of that murmur.
Dr. Andy Roark:
Yeah, I’ve not heard anyone say the phrase loss of a cardiac waste in 14 years. It’s like I remember that phrase and no one said it to me a long time.
Dr. Anna McManamey:
Well, coming back from the-
Dr. Andy Roark:
Really, it just came flashing back. I was in a classroom in Gainesville, Florida. I was like, oh yeah. My recollection of radiographs, just stepping to that, yes, cardiac enlargement. Do you see the actual stenosis in these? Can you see in the vessels, anything like that as 100% just looking for signs of change in the heart itself? I’m just trying to get my head around… I’m just trying to remember back to what that looks like in severe, so pause. In my recollection, there were radiographs in that school that I looked at that 100% showed the pinch stenotic of vasculature coming out. Is that is a thing that we’re ever going to see, or are we a 100% assessing the heart itself?
Dr. Anna McManamey:
With traditional radiography, you’re not going to see that because you’re just going to see soft tissue and blood superposed. Those are going to be the same opacity. In the good old days, they did radiograph angiograms. In school, they probably showed you some really cool images where they did an injection of contrast and then looked at a radiograph. You can see that level of stenosis and you can see the heart chambers. Now we use echo for those things. Then we do angiograms in our cath labs when we’re doing procedures.
Dr. Andy Roark:
Got you. Okay. Talk to me a little bit about the echocardiogram. I know that most of the GPs are probably not running them. Just easy to find. Is there any pearls or words of wisdom, anything that I want? When I refer this, if I have an internist come and look at things like that, do I want to say anything to them or just go, it’s an echo and they’re going to look and they’re going to be, here’s your problem.
Dr. Anna McManamey:
Yeah. No, it’s a great question. I think this is sometimes a little bit of a delicate subject, especially amongst cardiologists and other specialists that do have the ability to do advanced imaging. I think most cardiologists feel that any congenital case, it’s probably best served by being echoed by somebody that has a lot of practice or has the ability for, even if they’re a radiologist that’s variable trained or an internist, sending those out for review by a cardiologist, just because some things are very basic and very simple about it, but there are other little nuances that are really important. Just because they only have one congenital heart disease, doesn’t mean they couldn’t have a second one that’s hiding. That’s really important for us because that is going to impact the way we treat those cases, the prognosis we give and the interventions we recommend. Ideally a cardiologist, if you can. Otherwise, someone with good echo technique, has a machine that’s specifically for echo and then has the ability to get that read by for you.
Dr. Andy Roark:
Got you. No, that’s a good reminder. That makes a ton of sense. Hey guys, I just want to jump in here real fast and give a shout out to Banfield Pet Hospital, for making our transcripts available. That’s right. We have transcripts for the Cone Of Shame vet podcast and the Uncharted veterinary podcast. You can find them at drandyroark.com and at unchartedvet.com. This is part of their effort to increase inclusivity and accessibility in vet medicine. We couldn’t do it without them. I got to say, thanks. Thanks for making the content that we put out more available to our colleagues. Guys, that’s all I got this time. Let’s get back into this.
Dr. Andy Roark:
Am I going to see anything if I do a blood pressure check on this patient? A lot of times, we’ll get patients in and just first thing we do, is check their blood pressure as we’re surgery prepping them. Am I going to see abnormalities there?
Dr. Anna McManamey:
That’s a great question. For better or for worse, the pulmonic and the systemic circulations are completely separated by the lungs. There’s no way to check what the pressure in the right side of the heart is with a systemic blood pressure. We have to rely on using our central venous pressures. A chief way to do it is look at the jugular veins. If the jugular veins are distended or bounding, where you can see the pulses, which is challenging in English bulldogs, I will say, but if you can see those things, that tells us there’s elevated right atrial pressure. If they have ascites already, distended abdomen, that would be an indication, but sadly, there’s no way short of really sticking something down into the heart to get a measurement of those pressures.
Dr. Andy Roark:
Got you. Okay. Are there breeds where you can pretty easily see the bouncing jugular veins, because I’m like, that’s a diagnostic test that I want to do now. I want to see that.
Dr. Anna McManamey:
Yeah. Yeah. It’s really cool. It’s kind of like horses. They can be normal up to about a third of the neck, out of the thoracic inlet. If you’ve got a really fit athletic dog that comes in and they’re super excited, you’ll actually see them sometimes just pulsing in the neck, but the ones that we’re looking for, the pulses that go all the way up the neck or where the jugular veins are so distended, you can see them just by wetting the fur with alcohol. You can actually see them standing up. My trick for the ones that are more difficult is to hold off the jugular vein like I would for venipuncture, so hold off at the thoracic inlet, find the vessel and then let go with my thumb. If I can still feel the vessel the same, it’s still that distended, I know it’s abnormal.
Dr. Andy Roark:
That’s super cool. I’m desperate now to see that so I can point across the treatment room and say to my technicians, “That dog has elevated right systolic pressure,” and they would look at me like Merlin walked in. I’ll be like, I can tell. I won’t tell, no, I didn’t. Just no. I can smell it.
Dr. Anna McManamey:
Exactly. Just wave your hand over. This dog has very systolic pressure.
Dr. Andy Roark:
Yes, exactly.
Dr. Anna McManamey:
It’s really helpful. It’s really helpful it and it’s for any cost. This could be a patient with bad heart disease. This could be a patient with bad [inaudible 00:14:48] disease, pulmonary hypertension. The same is true with the only tricky one is with tamponades. If you’ve got pericardial effusion in tamponades, you’ll likely see jugular pulsations, so helpful too.
Dr. Andy Roark:
Well, let’s fix this. What are my treatment options? What am I going back to the pet owners with when I say, Hey, unfortunately, this is what I found? Obviously, we’re not going to go do this procedure today. Instead, we’re going to work up a new treatment plan. What do you think that treatment plan looks like?
Dr. Anna McManamey:
Typically, it all starts with diagnosis. Again, going back, getting that echo, finding our formal diagnosis and then probably, the more important parts of how significant is it? There’re grades of pulmonic stenosis and there’re types of pulmonic stenosis. The most common kind of pulmonic stenosis we see is truly of the valve itself. It’s where the valves leaflets, they all formed like they were supposed to, except they never separated into three leaflets. We just have this mush of leaflets that are doming. They never open all the way so it’s a valvular pulmonic stenosis. We used to call these type A, meaning they were very amenable to going in and doing a balloon procedure, which we’ll come back to in a second. The other type is this type B morphology, which is, unfortunately, what the bulldog seemed to be plagued with more often.
Dr. Anna McManamey:
That’s where the whole anulus itself, so the circumference of the valve is smaller than normal. The whole thing just is underdeveloped. Those animals may not be as amenable to balloon procedure, but we have to echo to find that out. There’re other levels of obstruction but again, the valve is the most common. French bulldogs are in a class of their own. They get this obstruction above the valve as well. We call it a supravalvular stenosis but again, echo answers that question for us. Once we know what kind, we have to know how bad is it? We use a few variables to help us with that. We’re basically just trying to say, is this obstruction mild, moderate, or severe? The easiest way is to use the speed of blood leaving the right ventricle tract obstruction, so it’s just like the garden hose effect.
Dr. Anna McManamey:
If you take your thumb over the edge of a garden hose, blood, or excuse, water speeds up, and it creates a turbulent jet. Same thing in the heart. The smaller that opening is, the more turbulent the blood flow is. We can use the speed of blood flow to tell us how severe the obstruction is. Classically, anything over a pressure gradient of 80 millimeters of mercury is considered severe. Normal, to put it in perspective is less than five millimeters of mercury. We’re talking way, way, severe. These animals have thick right hearts. They might be symptomatic. They may not at the time of diagnosis, but the concern is that they will become symptomatic. They could develop congestive heart failure in their life. Honestly, by the time they’re five to six years of age, they could die suddenly from arrhythmia.
Dr. Anna McManamey:
It’s these severe categories that we want to treat. The two mainstays of treatment are medical versus interventional. The medical tried and true drug that we usually put these guys on is one called Atenolol, for some type of beta blocker. This is common throughout literature and things. I think there’s a common misconception that when we put them on Atenolol, it makes their stenosis better. It doesn’t do anything to the anatomy of the valve. What it does, is it reduces the workload on that heart and the myocardial oxygen demand in the heart. Beta blockers slow heart rate. They reduce contractility. Those are two determinants of cardiac oxygen demand. We’re trying to protect the heart muscle from arrhythmias, from progressive changes and trying to prevent their heart rates from getting too fast., so that way they hopefully have a longer prognosis and a better survival time.
Dr. Anna McManamey:
Ideally, we take them to the cath lab. That’s one of my favorite things to do. We take them to the cath lab and we do the balloon valvuloplasty. This is where we actually take our special catheters, go in through the heart and we can access through the jugular vein or the femoral vein. We go in and we basically inflate these special catheters. It’s a balloon. Inflate it across the bowel and we tear open those leaflets. The medical management is, of course, very cheap. Atonolol is a very readily available drug. It’s very cheap. Minimal side effects. Again, it doesn’t change their anatomy. It just protects their heart muscle from the negative effects of that disease.
Dr. Anna McManamey:
The interventional approach is usually going to be a few thousand dollars. It’s usually only available at specialty hospitals with cardiologists that also have a cath lab. Almost every academic institution does it. Not as many private practices do, but this is our bread and butter. We’re usually doing two to three of these a week at [inaudible 00:19:25], for example. Those dogs, we think, typically, have a success rate of about 80% of the time. Sometimes that valve stenosis re-narrows, and we have to do it a second time. Sometimes the anatomy is such that we can’t inflate the balloon appropriately or despite our best efforts, that valve doesn’t want to budge. Now, there’s even newer techniques like placing stents in there and doing some really cool stuff, but that’s all something that can be discussed with the cardiologists and that client at the time of the appointment.
Dr. Andy Roark:
Got you. Okay. Let me ask a potentially silly question, but it makes some sense to me anyway. If I have this dog and they have pulmonic stenosis and we’re talking about, let’s say medical management. We’re not going to go in surgery but we repair this. Is there clinical benefit to, at some point, when the patient is a stable, solid surgical candidate to doing this brachycephalic airway surgery, to open it up, to increase oxygenation to the dog. As I think about that, and I get 100% see in my mind, talking to the pet owners and saying, “Hey, this is where we are and we’re going through the process.” Then they panic and say, “Oh my God. Well, she’s so fragile. We definitely don’t want to do surgery.”
Dr. Andy Roark:
Is there a place where I say, “Well, let’s manage this. There’s still benefit to doing this airway surgery.” I believe that for the comfort of the patient. I do believe that but let me ask you, is there clinical benefit to a pulmonic stenosis patient, that’s a bulldog, to be able to breathe?
Dr. Anna McManamey:
Yeah. No, I think absolutely there is. It becomes this very delicate balance of, okay, well I found a heart disease in this pet. If it’s mild to moderate stenosis, you’re done. They can go get their procedure. They’re on some Atenolol. It’s fine. Well, then that severe category, you really think, wow, ballooning, this dog would make it a more stable anesthetic candidate. Doing its airway would make it a more stable anesthetic candidate. Actually, there are a number of these dogs where they have severe enough problems of both that I have them come to me. I balloon them and then have my surgeon do their airway before they wake up.
Dr. Andy Roark:
Wow.
Dr. Anna McManamey:
That’s what I’ll do. If I have a client that is dedicated to doing those things, we’ll do it. It makes my anesthesiologist happy because these dogs are not the fun ones to anesthetize. They’re hypotensive. Some of them have intra cardiac shunts. They’ve got shunting across their atrial levels. They’re not very fun to anesthetize if they have severe, severe stenosis, but you’re exactly right. A lot of these dogs, I do think can be more clinically affected from their airway than from their heart, at least at that point in time. Maybe there’s that acceptable risk that you have a skilled anesthetist who’s comfortable with a quick procedure, a surgeon who’s comfortable with a quick procedure to just make that dog clinically better in the short term.
Dr. Andy Roark:
Can you give me an idea of prognosis for mild, moderate and severe with and without surgery?
Dr. Anna McManamey:
Yeah.
Dr. Andy Roark:
Six answers. That’s a six-answer question.
Dr. Anna McManamey:
Well, I’ll lump it into three. If it’s mild to moderate stenosis, we rarely recommend interventional procedures for those dogs. There’s been enough evidence that for most dogs, as long as they’re in the mild to moderate category, they’re not expected to have negative side effects from their heart disease in their lifetime. It’s very uncommon. There are some exceptions to that, like larger breed dogs. It seems they seem to be a little bit more sensitive to even moderate degrees of stenosis. We use the changes to the heart more than anything. If their heart looks like it’s thick, we’ll say, let’s go do this and get rid of it, and try and give them their best chance at life for the severe dogs, so gradients over 80. This is, honestly, a very wide range of dogs because we’ve got tons of dogs that have gradients over 200.
Dr. Anna McManamey:
That dog is going to have a worse prognosis than the dog of 85, but they’re still both severe, so it’s a little bit fuzzy there, but the median survival time for dogs with severe stenosis without intervention is about five to seven years of age. Usually, those dogs are dying from their heart disease. That’s when we talk about its cardiac causes of death so it’s refractory heart failure, progressive syncarpy that can’t be controlled, exercise intolerance or arrhythmias and sudden death. Those are the more common outcomes that we’ll see, but usually, it’s probably around five years of age is when it really starts seeing to be the worst. With intervention, if we are successful, meaning we get them into at least a 50% reduction of their initial gradient, or whole [inaudible 00:23:52] to get them out of the severe category. If we do that, then they have, essentially, a normal life expectancy. That’s the cell. It sounds like a lot upfront, even if the dog is asymptomatic at that time, but we’re trying to get you years of quality of life with the dog dying from something other than the heart disease.
Dr. Andy Roark:
That makes total sense. Dr. Mac, thank you so much. Are there any final pearls, words of wisdom or pitfalls that I need to look out for as I head forward with this case?
Dr. Anna McManamey:
I would just say, I think you’ve done the best things. Everything else can be done, honestly, under the guidance of the cardiologist and just a team approach with everything, but the breeds I’d watch out for, every bulldog. Frenchy, English doesn’t seem to matter. Any terrier breeds, pit bull terriers, Norfolk terriers, west highland white terriers. Those ones are the most commonly affected. It could be any breed. Just every time you’ve got that new puppy in the room, listen really high up in the axilla region at the base of their heart to find these murmurs early.
Dr. Andy Roark:
That’s fantastic. Thanks again.
Dr. Anna McManamey:
You’re welcome.
Dr. Andy Roark:
That is our episode. Guys, I hope you enjoyed it. I hope you got a ton out of it. I know I did. Thanks to Dr. Mac for being here. Guys, take care of yourselves. Be well, talk to you soon. Bye.
