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Journal of Veterinary Cardiology (2014) 16, 237e244

www.elsevier.com/locate/jvc

Two-dimensional cardiothoracic ratio


for evaluation of cardiac size in German
shepherd dogs
Faisal A. Torad, BVSc, MVSc, PhD ,
Elham A. Hassan, BVSc, MVSc, PhD*
Department of Surgery, Anesthesiology and Radiology, Faculty of Veterinary Medicine,
Cairo University, Giza Square P.O. 12211, Cairo, Egypt
Received 14 November 2013; received in revised form 8 August 2014; accepted 18 August 2014

KEYWORDS
Radiography;
Heart;
Cardiomegaly;
Microcardia;
Canine

Abstract Objectives: To evaluate cardiac size in normal German shepherd dogs


(GSD) using the two-dimensional cardiothoracic ratio (CTR) and to use this measure
for diagnosing GSD with altered cardiac size.
Animals: One hundred clinically normal GSD as well as 46 GSD with altered cardiac
size (microcardia or cardiomegaly).
Methods: The CTR was computed as the percentage area of the cardiac silhouette
relative to the area of the dogs thorax. Measurements were performed using a digital software program on lateral and ventro-dorsal radiographs at the points of
peak inspiration and expiration. Receiver operating characteristic (ROC) curve analysis was used to determine the diagnostic accuracy of the CTR for diagnosing cardiomegaly or microcardia.
Results: The mean ( SD) CTR on lateral radiographs of normal dogs was
27.60%  1.10% and 30.13%  1.42% at the points of peak inspiration and expiration,
respectively. For ventro-dorsal radiographs, mean CTR was 30.45%  1.39% at peak
inspiration and 33.34%  1.46% at peak expiration. The cutoff value of the CTR for
diagnosing microcardia on lateral radiographs was 22.98% (inspiration) and 25.06%
(expiration), compared to 25.03% (inspiration) and 23.97% (expiration) on ventrodorsal radiographs. Cutoff values for diagnosing cardiomegaly were 30.28% (inspiration) and 33.44% (expiration) on lateral radiographs and 36.80% (inspiration) and
37.99% (expiration) on ventro-dorsal radiographs.

* Corresponding author.
E-mail addresses: elhamhassan@cu.edu.eg, elham_a.
gawad@yahoo.com (E.A. Hassan).
http://dx.doi.org/10.1016/j.jvc.2014.08.001
1760-2734/ 2014 Elsevier B.V. All rights reserved.

238

F.A. Torad, E.A. Hassan


Conclusions: CTR may provide a clinically useful tool for evaluating cardiac size in
dogs.
2014 Elsevier B.V. All rights reserved.

Abbreviations
AoD
AUC
CI
CTR
FS
GSD
LADs
LVIDd

aortic root dimension


area under the curve
confidence of interval
two-dimensional cardiothoracic ratio
fractional shortening
German shepherd dogs
left atrial dimension at end-systole
left ventricular internal dimension at
end-diastole
LVIDs left ventricular internal dimension at
end-systole
ROC
receiver operating characteristic
RVIDd right ventricular internal dimension at
end-diastole
VHS
vertebral heart scale

be detected by VHS. Considerable changes in the


cardiac contour can exist without subsequent
dilatation, as in diseases which cause concentric
hypertrophy.1,10,11 The development of an objective method for evaluation of cardiac size based on
the entire cardiac silhouette may provide a useful
tool for diagnosing subtle changes in cardiac size as
well as generalized cardiac enlargement.
We hypothesize that cardiac size can be evaluated through evaluation of the cardiac area in
comparison to the thoracic area in dogs by use of a
two-dimensional cardiothoracic ratio (CTR). The
purpose of the present study was to evaluate the
cardiac size in normal German shepherd dogs (GSD)
using CTR, and to use this measure for evaluating
dogs with cardiomegaly or microcardia.

Materials and methods


Dogs and radiography

Introduction
Evaluation of cardiac size is an important clinical
variable in dogs1 and changes in cardiac size may
be used to monitor and grade disease severity.2
However, a normal cardiac size does not rule out
the presence of disease.1 Various diagnostic tools
have been used to evaluate cardiac size including
thoracic radiography, echocardiography and electrocardiography.3 Thoracic radiography remains
the most commonly used method.4,5
Subjective radiographic evaluation of cardiac
size with a guide of 2.5e3.5 intercostal spaces on
the lateral projection is commonly used in canine
practice.6e8 The limitations of this subjective
evaluation may include superimposition of the ribs
as well as the effects of breed, thoracic conformation, and phase of respiration.1,8,9 An objective evaluation of cardiac size using the vertebral
heart scale (VHS) is a widely accepted method first
described by Buchanan and Bucheler in 1995.1 The
VHS measurement is based on measuring the cardiac height (long axis) and width (short axis) compared to the animals vertebral body length. A
possible limitation of the VHS is that it relies only on
two linear measurements for evaluation of cardiac
size and not to the entire cardiac circumference.
Therefore, subtle changes in cardiac size may not

The present study was done in 146 GSD. All study


procedures were approved by the animal care and
use ethical committee of the Faculty of Veterinary
Medicine, Cairo University. One hundred healthy
client-owned GSD (67 males and 33 females) aged
2.8  0.6 years old and weighing 31.2  5.4 kg were
admitted to the clinic of the Department of Surgery,
Anesthesiology and Radiology, Faculty of Veterinary
Medicine, Cairo University for routine examination.
Dogs included in the study were free of clinical signs
of cardiovascular or respiratory disease. All dogs
were evaluated by physical examination, electrocardiography (standard 12-lead ECG) and echocardiography before enrollment in the study. In
addition, 46 GSD (30 males and 16 females) aged
3.1  0.5 years and weighing 30.8  5.2 kg were also
included in the study. These dogs were diagnosed
with altered cardiac size (cardiomegaly or microcardia) based on subjective radiographic evaluation
(hearts less than 2.5 or more than 3.5 intercostal
spaces based on lateral radiographs),6e8 echocardiography (according to values obtained from
previous studies on normal GSD)12,13 and electrocardiography.14 The 46 GSDs with altered cardiac
size included 35 dogs with cardiomegaly [dilated
cardiomyopathy (n 16), persistent arterial duct
(6), mitral insufficiency (5), aortic insufficiency (3),

Cardiac size in German shepherd dogs


tricuspid insufficiency (2), hypertrophic cardiomyopathy (2), pulmonic stenosis (1)] and 11 dogs with
microcardia.
All examinations were performed without
sedation or anesthesia. Four sets of radiographs
were taken of each dog consisting of right lateral
and ventro-dorsal thoracic radiographs at both
peak inspiration and peak expiration. On lateral
radiographs, the point of full inspiration was
defined as the time point when the lumbodiaphragmatic angle was located caudal to the
12th thoracic vertebra (T12), while the point of
maximal expiration was defined as the time when
the lumbo-diaphragmatic angle was located cranial to the 11th thoracic vertebra (T11). On the
ventro-dorsal radiographs, the point of full inspiration was determined as the phase when the
costo-diaphragmatic angles were caudal to the
10th thoracic vertebra (T10) and peak expiration
defined as the time at which the diaphragmatic
dome was positioned caudal to middle of the 8th
thoracic vertebra (T8).2,15
Radiographic positioning was assured by the
same radiologist using a standardized positioning
technique.16 The radiographs were taken using a
grid of medium (400) speed and (0.2  30  40 cm)
dimensions, as well as settings of 70e80 kVp and
3 mAs with a focal film distance of 70e90 cm.
Analog radiographs for all dogs were analyzed,
scanned and transferred to a computer system for
measurement of VHS and CTR.

239
program and the result was expressed as units of
vertebral length (v).
For measuring the cardiac area on lateral and
ventro-dorsal radiographs, the area measuring
tool of the software program was used to trace the
contour of the cardiac silhouette along the cranial
cardiac border and waist, cardiac apex, caudal
cardiac border and waist, cardiac base and again
at the cranial border. For measuring the thoracic
area on lateral radiographs, the area measuring
tool of the program was used to track the contour
of the thoracic cavity in a closed path along the
ventral border of the thoracic vertebrae, lumbodiaphragmatic angle, crura of the diaphragm,
sterno-diaphragmatic angle, dorsal border of the
sternum, thoracic inlet and back to the start point
at the ventral border of the thoracic vertebrae
(Fig. 1). On the ventro-dorsal radiographs, the
thoracic area was traced from the thoracic inlet,
lateral thoracic wall, costo-diaphragmatic angle,
diaphragmatic dome, costo-diaphragmatic angle
and lateral thoracic wall of the other side and
again to the starting point at the thoracic inlet
(Fig. 2). The cardiac area and thoracic area were
expressed in mm2, all the obtained data were
transferred to a spreadsheet, and the CTR was
then calculated using the following equation: twodimensional cardiothoracic ratio (CTR) cardiac
area/thoracic area * 100.

Radiographic measurements
All radiographs were labeled and randomized for
blind examination. Radiographic measurements of
the VHS and CTR were done by the same examiner
(E.A.H.) using a commercial software program.a
The examiner was blinded to the results of other
findings.
Measurement of the VHS was done in accordance with the method previously described.1 On
lateral radiographs, the long axis of the heart was
measured starting from the ventral border of the
largest main-stem bronchus (carina) to the most
distant point of the cardiac apex. The short axis
dimension was measured at the level of the caudal
vena cava on a line perpendicular to the long axis.
The measurements of the two axes were then
compared to the vertebrae starting at the cranial
edge of T4 using the unit measuring tool of the

a
Digimizer 4.2.2.0 image analysis software, MedCalc Software bvba, Ostend, Belgium.

Figure 1 Right lateral thoracic radiograph of a healthy


German shepherd dog during peak expiration demonstrating tracking of the cardiac and thoracic contour
using Digimizer Software. The cardiac silhouette is
tracked along the cranial cardiac border and waist,
cardiac apex, caudal cardiac border and waist, cardiac
base and again at the cranial border. The thoracic cavity
is tracked in a closed path along the ventral border of
the thoracic vertebrae, lumbo-diaphragmatic angle,
crura of the diaphragm, sterno-diaphragmatic angle,
dorsal border of the sternum, thoracic inlet and back to
the start point at the ventral border of the thoracic
vertebrae.

240

F.A. Torad, E.A. Hassan


Receiver operating characteristic (ROC) curve
analysis was used to determine the diagnostic
accuracy and the cutoff values of the CTR of normal
dogs and those with microcardia or cardiomegaly
based on the measurement of left ventricular
internal dimension at end-diastole (LVIDd) using
graphing software.c

Results

Figure 2 Ventro-dorsal thoracic radiograph of a


healthy German shepherd dog during peak expiration
demonstrating tracking of the cardiac and thoracic
contour using Digimizer Software. The cardiac silhouette is tracked along the cranial cardiac border and
waist, cardiac apex, caudal cardiac border and waist,
cardiac base and again at the cranial border. The
thoracic cavity is tracked in a closed path starting from
the thoracic inlet, lateral thoracic wall, costodiaphragmatic angle, diaphragmatic dome, costodiaphragmatic angle and lateral thoracic wall of the
other side and again to the starting point at the thoracic
inlet.

Statistical analysis
Data were expressed as mean  SD and were
analyzed by a commercial software program.b
Repeated measures analysis of variance (ANOVA)
was used for the comparison within and between
groups. When a significant difference was recorded, a post hoc test (least significance difference)
was used to determine how the means differed.
The results were considered statistically significant at P < 0.05.

b
IBM SPSS Statistics for Windows, Version 21.0, Armonk, New
York, USA.

The GSDs included in the study were of similar age


and body weight and no statistically significant
differences were found in age or body weight
within or between the three groups.
The mean echocardiographic measurements of
normal, microcardia and cardiomegaly groups are
tabulated in Table 1. Results of ROC curve analysis
and the cutoff value of the echocardiographic
measurements are presented in Table 2.
The mean CTR in different groups at the different radiographic projections are demonstrated in
Table 3. Data obtained from the ROC curve analysis
and the cutoff values of the CTR in different
radiographic positions are tabulated in Table 4.
In dogs with normal cardiac size based on subjective radiographic, electrocardiographic and
echocardiographic evaluations, the mean (SD,
minimum to maximum) VHS was 9.8  0.5,
9.2ve10.3v. In dogs with reduced cardiac size
(microcardia) based on echocardiography and
subjective radiographic evaluation (less than 2.5
intercostal spaces on lateral radiographs), the
mean VHS was 9.4  0.6, 9.2ve10.1v. The dogs
with cardiomegaly had a mean VHS of 10.5  0.4,
with a minimum to maximum of 10.2ve10.9v.

Discussion
In the present study, an attempt was made using
the CTR to evaluate cardiac size relative to thoracic size to provide an objective diagnostic tool for
evaluation of cardiac size in the GSD breed. It has
been suggested that a reliable method of cardiac
evaluation should be based on the comparison of a
dogs radiographs with those of normal dogs of the
same breed.16 In this study, measurements of the
CTR were done on a large number of clinically
normal GSD, with GSD selected to eliminate interbreed variations of cardiac size and shape.11,17e21

c
SigmaPlot 12.5 Exact Graphs and Data Analysis Software,
Systat Software Inc., San Jose, California, USA.

Cardiac size in German shepherd dogs

241

Table 1 Mean echocardiographic measurements (SD, minimumemaximum) and coefficients of variation (italic)
in the three groups of German shepherd dogs studied.
Echocardiographic measurement

Normal
(n 100)

Microcardia
(n 11)

Cardiomegaly
(n 35)

LVIDd (mm)

45.2  2.2A,B
(41.3e49.7)
4.8
33.0  1.0C,D
(31.0e35.5)
3.0
24.4  0.2E,F
(24.0e25.0)
0.9
11.6  0.9G,H
(10.0e13.4)
8.1
25.9  0.9I
(24.3e27.5)
3.5
27.0  4.3J,K
(22.5e36.7)
15.8

36.3  1.6A
(34.6e39.2)
4.3
27.6  1.0C
(25.7e28.8)
3.7
22.2  1.6E
(20.5e25.4)
7.0
9.4  0.6G
(8.6e10.2)
6.2
21.8  1.1I
(20.1e23.0)
5.1
24.0  4.6J
(17.3e31.4)
19.3

53.1  1.3B
(50.3e55.5)
2.5
36.9  0.8D
(35.5e38.0)
2.1
27.0  0.9F
(24.9e28.9)
3.3
14.5  0.9H
(12.5e16.0)
6.3
26.2  1.0
(24.6e28.0)
3.7
19.9  2.3K
(14.5e21.1)
9.9

LVIDs (mm)

LADs (mm)

RVIDd (mm)

AoD (mm)

FS (%)

LVIDd Left ventricular internal dimension at end-diastole; LVIDs Left ventricular internal dimension at end-systole;
LADs Left atrial dimension at end-systole; RVIDd Right ventricular internal dimension at end-diastole; AoD Aortic root
dimension; FS Fractional shortening.
Within a row, identical superscript letters indicate significant differences between the normal group and the abnormal group
(either microcardia or cardiomegaly) (P < 0.05).

Variations of the radiographic cardiac size that


may arise from inconsistent positioning of the animal or phase of respiration19,20 were eliminated by
the use of the same evaluator, standardization of
radiographic positioning, and consideration of the
phase of respiration. Although it has been reported
that cardiac size evaluated by the VHS does not
change with the dogs age and developmental
stage,22 the dogs used in the study were of similar
age and weight range in each group.
Radiographic evaluation of cardiac disease is
based mainly on the evaluation of the size and
shape of the cardiac silhouette.16,23 Increased

cardiac size is expected in dogs with cardiac dilatation, eccentric hypertrophy16,23e26 as well as
pericardial effusion.27,28 During the cardiac cycle,
variation of the cardiac size may be expected.
However, use of the cardiac silhouette for evaluation of cardiac size assumes that the overall cardiac
size will not change substantially as ventricular
contraction will be associated with atrial relaxation
and vice versa.
Initial attempts at measuring the CTR for evaluation of cardiac size in the late 1960s and early
1970s measured the cardiac and thoracic dimensions using a simplified linear method on lateral

Table 2 Receiver operating characteristic (ROC) curve analysis of echocardiographic measurements in the
prediction of microcardia and cardiomegaly in German shepherd dogs.
Echocardiographic measurement
Cutoff
LVIDd (mm)
LVIDs (mm)
LADs (mm)
RVIDd (mm)
AoD (mm)
FS (%)

Cardiomegaly
(n 35)

Microcardia
(n 11)
40.3
29.9
23.3
9.9
23.7
31.4

AUC  SD

95% CI

Cutoff








1.00e1.00
1.00e1.00
1.00e1.00
0.99e1.00
1.00e1.00
0.50e0.85

50.0
35.2
25.3
13.5
27.6
23.1

1.00
1.00
1.00
1.00
1.00
0.68

0.00
0.00
0.00
0.01
0.00
0.09

See Table 1 for key. AUC area under the curve; CI confidence of interval.

AUC  SD

95% CI








1.00e1.00
0.99e1.00
1.00e1.00
0.96e1.00
0.48e0.71
1.00e1.00

1.00
0.99
0.99
0.98
0.59
1.00

0.00
0.00
0.00
0.01
0.06
0.00

242

F.A. Torad, E.A. Hassan

Table 3 Mean cardiothoracic ratio (SD, minimumemaximum) and coefficients of variation (italic) in the 3
groups of German shepherd dogs studied at different radiographic positions.
CTR (%)
Lateral

Inspiration

Expiration

Ventro-dorsal

Inspiration

Expiration

Normal
(n 100)

Microcardia
(n 11)

Cardiomegaly
(n 35)

27.60  1.10a,c,A,B
(24.04e30.45)
0.05
30.13  1.42a,d,C,D
(25.05e32.99)
0.04
30.45  1.39b,c,E,F
(27.08e33.74)
0.05
33.34  1.46b,d,G,H
(24.45e35.87)
0.03

21.96  0.58e,g,A
(20.29e21.93)
0.03
22.01  0.46e,h,C
(21.05e22.59)
0.02
22.46  0.43f,g,E
(21.69e22.97)
0.02
22.80  0.40f,h,G
(22.04e23.48)
0.02

33.97  1.13i,k,B
(30.11e35.84)
0.03
35.25  0.86i,j,D
(32.65e36.98)
0.02
41.66  1.13j,k,F
(39.87e43.78)
0.03
43.34  1.25j,l,H
(40.11e44.87)
0.03

CTR cardiothoracic ratio.


Within a row, identical superscript capital letters indicate significant differences between the normal group and the abnormal
group (either microcardia or cardiomegaly) (P < 0.05).
Within a column, identical superscript small letters indicate significant differences between radiographic positions within the
same group (P < 0.05).

radiographs,29e31 but this linear measurement was


not sufficient to differentiate between normal and
enlarged hearts. In the present study, the use of a
two-dimensional CTR for evaluation of cardiac size
was done by tracking the overall cardiac and
thoracic contours using a software program rather
than linear measurements. In addition, the CTR
determination of normal heart size in this study
was compared against a gold standard (echocardiography). The cutoff value of the CTR at the
points of peak inspiration (30.28%) and expiration
(33.44%) could be considered an early indicator of
subtle changes in cardiac size.
In normal GSD, the mean VHS (9.8v  0.5v) was
similar to findings of a previous study in GSD
(9.7v  0.8v).17 While dogs diagnosed with microcardia based on subjective radiographic evaluation
had a VHS similar to the group of control dogs
without statistically significant differences, we
assume that the decrease in the cardiac width

(short axis) was offset by an increase in the cardiac


length. The upper limit of the reported VHS in
normal dogs in the present study (10.3v) overlapped with the lower limit of the dogs having
increased cardiac size (10.2v). Therefore the
threshold value of the VHS in GSD is in agreement
with the reported 10.2 v in a previous study.17 Many
dogs with a change in cardiac size (microcardia or
cardiomegaly) based on subjective and echocardiographic evaluation had a VHS within the reference range; this result was similar to findings of a
previous study.1 On the other hand, some of the
healthy GSD had VHS values above the reference
range, as has also been shown in a previous study.11
It has been reported that the diagnostic accuracy of
VHS for diagnosing cardiac disease in GSD is 75%.14
Prior reports found that VHS measurement is not
affected by the experience of the examiner.32
However, some difficulties may exist in determination of the reference points of cardiac axes

Table 4 Receiver operating characteristic (ROC) curve analysis of cardiothoracic ratio measured at the different
radiographic positions in the prediction of microcardia and cardiomegaly.
CTR (%)

Lateral
Ventro-dorsal

Microcardia
(n 11)
Inspiration
Expiration
Inspiration
Expiration

Cardiomegaly
(n 35)

Cutoff

AUC  SD

95% CI

Cutoff

AUC  SD

95% CI

22.98
25.06
25.03
23.97

1.0
1.0
1.0
1.0






1.00e1.00
1.00e1.00
1.00e1.00
1.00e1.00

30.28
33.44
36.80
37.99

1.0
1.0
1.0
1.0






1.00e1.00
0.99e1.00
1.00e1.00
1.00e1.00

See Tables 2 and 3 for key (P < 0.0001).

0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00

Cardiac size in German shepherd dogs


during VHS measurement.32,33 One of the main
limitations of using conventional measuring tools
and graduated rulers in VHS measurement is the
need for estimation of proportions when cardiac
length and width do not span by a whole number of
vertebrae. This was reduced in our study by using a
software program incorporating a digital calculation of the exact heart length and width, which
were then automatically expressed as units of
vertebral length.
The significant increase in the mean CTR during
expiration compared to inspiration could be
attributed to decreased thoracic area as the heart
will be surrounded by less aerated lung. The difference in thoracic area between expiration and
inspiration is expected to be equal to the volume
of inspired or expired air in one breath (tidal volume). The CTR was more increased in dogs with
cardiomegaly on the ventro-dorsal radiographs as
compared to the lateral images, which may suggest that the increase of cardiac size in these dogs
occurred in the latero-medial direction more than
in the cranio-caudal direction. A previous study
also reported that the mean VHS is significantly
larger in ventro-dorsal or dorso-ventral radiographs as compared to lateral radiographs.10
The main limitation of using CTR is the difficulty
in its applying this measurement to dogs with
pericardial effusion, perihilar pulmonary edema,
or moderate to severe pleural effusion where
there is loss of architectural details of the thoracic
cavity by the accumulated fluids. Also, the CTR is
not recommended for dogs with pneumothorax as
the thorax appears overinflated by the escaped air,
which may lead to an inaccurate measurement.
Limitations of the study include the use of analog
radiographs that required scanning prior to transfer to the computer system. Also the study was
done on only one breed of dogs (GSD); further
studies are required for setting breed specific
normal ranges and prior to applying the CTR to the
evaluation of cardiac size on a large scale. In
addition, data on the inter-observer variability of
CTR measurement is needed.

Conclusions
This study provides reference values for the evaluation of cardiac size in GSD based on the cardiac
silhouette using the CTR. The CTR may be considered together with other clinical data for the
evaluation of GSD with potential heart disease.
The ease of tracking the radiopaque cardiac contour and radiolucent thoracic contour as well as

243
the simplicity of the calculation favor the use of
the CTR in evaluating the cardiac size of GSD.

Conflict of interest statement


The authors declare no conflict of interest related
to this report.

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