According to Encyclopedia Britannica, the Balkans are usually said to consist of Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Kosovo, the Republic of Macedonia, Montenegro, Romania, Serbia, Slovenia, while Greece and Turkey are often included. After the post-Cold War period the region is still an economically depressed area. In spite of this, the passion and willingness of the veterinary world to grow and improve to a higher level, is more than alive.

It is very hard to practice medicine when the economic situation does not allow you to do the best you can. In addition, your clients are not able to handle expensive examinations and procedures. The Balkan veterinarians are heroes. They work in hard environment and only their love and willingness to know more and do their best for the animals keep them going. The veterinarians can go abroad to more developed countries to raise their knowledge and experience, but again the financial part of this educational experience stops them in a way. They are lucky to have strong and wonderful Associations which support their desire to further improve. All local associations, which in fact face the same difficult economic and financial situation, do it on a high professional level. For example, RoSAVA (Romanian Small Animal Association) makes huge veterinary event with 4 rooms every year, so veterinarians are able to choose the field and the subject of their interest. On the Balkans, we can take RoSAVA as a model for a job well done. All countries have their own Small Animal Association and all of them are working perfectly.

Today I will present several clinical reports from each country on the Balkans.

Open Heart Surgery for a Left Atrial Mass Extraction During Cardio-Pulmonary Bypass (CPB) in a 9-Year-Old Labrador Dog

Ranko Georgiev¹, Stoyan Nikolov¹, Nadezhda Petrova¹, Georgi Ignatov^2
1DVM; ²MD Thoracic Surgery

Introduction

Open heart surgery during a cardiopulmonary bypass is the only effective approach for some diseases that require an access to the heart chambers or the great vessels; even when a temporary inflow occlusion is chosen as an alternative, only a very few “time restricted” procedures could be done on a beating heart. However, when considering an open heart surgery, the high risk of intra- and post-procedure complications often outweighs the benefits. In veterinary medicine the financial weight of such a procedure is also a limiting factor.

Case Presentation

Arthur is a 9-year-old MC Labrador, trained like a guide dog for a blind person, admitted because of increasingly frequent exercise intolerance episodes during the past few months. Furthermore, the last week the patient was very weak and experienced several syncopal episodes. On a clinical presentation with the referring vet a tachycardia and dyspnea were noted and the patient was referred to us for a cardiology consult.

Surgical Approach

The surgical approach was through the left fifth intercostal space with a standard lateral thoracotomy. Additionally the left carotid artery was approached and prepared in case it is needed for the CPB blood return. The pericardium was excised and the left atrium, the big vessels and the left ventricle visualized. Then three cannulas were put - the one collecting the venous blood inside the right atrium (through the right atrium auricle), the one returning the oxygenated blood from the CPB machine into the ascending aorta and one small cardioplegic cannula into the aortic root over the coronary arteries. Then a bolus of heparin was injected IV in a dose of 800 IU/kg and 5 minutes later the patient was switched to the heart-lung machine (Sorin 5 and a pediatric oxygenator with 360 ml prime). Then we started a controlled cooling of the patient using a chiller, connected to the CPB machine. When the target body temperature of 28°C was reached the ascending aorta was cross clamped and a 600 ml of cooled to 4°C crystalloid cardioplegic infusion rich in potassium was infused through the coronary cannula producing complete heart arrest. We stopped the active ventilation of the lungs and the patient became fully dependent of the heart-lung machine. The heart was open through a 5-cm cut into the left atrial wall starting from the auricle tip. The mass was directly visualized and excised. It was connected to the intra atrial septum with a relatively small neck. We removed it without creating an ASD. The air from the heart was evacuated and the surgical cut closed with a 5-0 polypropylene suture in a continuous way. The mass was a solid and well defined structure with irregular shape and was admitted for histology. The size was 8/6/4 cm.

We started a slow rewarming of the patient with a target body temperature of 38°C. Two epicardial electrodes were embedded and connected with an external pacemaker. Once closed and warmed, the heart was gently massaged manually for a couple of minutes and then hit with a direct pediatric defibrillator. We used 5 to 20 J of energy shocks and got a slow and then faster rhythm after the 9th try. The external pacemaker was switched on and put on a 100 bpm rate for the next 12 hours. The surgical closure was uncomplicated and no significant bleeding was noted. The patient received slowly IV Protamin (1 mg/100 IU heparin) as a heparin antidote and the heart-lung machine was gradually restricted and then switched off. Two chest drains were put and connected to a sterile active suction. The total machine time was 130 min, the sinus arrest time - 22 min, total surgery time - close to 5 hours. Immediately after the CPB machine was stopped a hemotransfusion with two units of fresh blood was done.

Ehlers-Danlos Syndrome (EDS) in Cat

Lucko, 7-month-old shorthair male mix breed cat, was represented to the clinic with uveitis, alopecia and multiple skin ulcerative wounds, located in the regions of the dorsum, thorax and head. He was treated for few months with antibiotics, ointments and corticosteroids with no success. The skin of the cat was extremely extensible and very fragile. It was very easy for the skin to be torn but with no bleeding at all. The cat had to be handle with gentle touch and care.

The diagnostic work-up included a complete blood count, blood serum biochemistry panel and urinalysis to rule out any internal disease associated with these skin lesions. CBC showed mild leucocytosis (white blood cell count: 19.5 x 10⁹, reference range: 5.0 x 10⁹–18.9 x 10⁹). In biochemistry analysis the changes were CK - 225 U/L (reference range: 17.00–150.20 U/L) and LDH - 427 U/L (reference range: 35.10–224.90 U/L).

Punch biopsy of the skin was performed together with Dr. Rares Capitan and sent for histological investigation in Romania. The histopathologic findings were compatible with feline cutaneous asthenia.

Tibial Nerve Peripheral Nerve Sheath Tumor in Dog

A 10-kg BW, 8,5-year-old Miniature Schnauzer was presented at the clinic with owners complaining of lameness on right hind limb for last five months.

At previous vet the dog was submitted to complete orthopedic, radiography and CT study with no diagnosis after the diagnostic workout. The dog was treated with 20 days of NSAID therapy (carprofen 2 mg/kg BID 10 days and the dosage was reduced by half for the next 10 days). There was no improvement so the dog was treated with prednisolone for 20 days SID with again very little improvement.

The dog doesn’t have any important data in medical history.

At the presentation in our clinic:

• During the walk dog showed grade one lameness.
• At the clinical examination the dog showed normal proprioception but reduced withdraw reflex on right hind limb.
• During palpation region of gastrocnemius muscle was markedly painful.
• The rest of neurology and orthopedic examination was in within normal limits.

CT Study

There is a focal dilation of a vascular structure, presumably a vein, caudal to the medial aspect of the right stifle. The vascular dilation/aneurism has a maximal diameter of 7.7 mm and extends over a distance of approximately 4 cm. Contrast filling of the dilated area is heterogeneous with some areas lacking contrast filling. The affected vessel is an anastomosis/branch between the caudal branches of the saphenous vein and the caudal proximal femoral vein.

MRI Study

On the right limb at the level of tibial nerve there is a lesion with heterogeneous contrast intake in long contact with blood vessel. The lesion is 3 cm long in diameter.

Lesion at the level of tibial nerve in close contact with saphenous vein and the caudal proximal femoral vein. Heterogeneous contrast intake.

The surgical approach was made from medial side at the level of proximal part of gastrocnemius muscle. The careful identification of blood supplies and nerve structure was needed. The healthy proximal and distal part of the nerve was identified and the excision with 3 cm margins has been done.

The dog was treated post operatively with antibiotics for 7 days (cephalexin 15 mg/kg BID), fentanyl patch for 3 days, carprofen 2 mg/kg BID for 7 days, gabapentin since 3th day 20 days 10 mg/kg TIO.

Neurological exam has been done after 1, 3, 6 and 12 months. The only abnormal finding 6 and 12 months post op was longer ground phase during walk and reduced withdraw reflex.

Discussion

Tibial nerve is in charged for the motor function of caudal aspect of tibia and fibula. Deficit in function shows clinical signs that look similar to orthopedic conditions. Ground phase is longer, calcaneus drops distally more than in contralateral limb. Sometimes we can see plantigrade stance. Orthopedic conditions similar to these in term of signs are pathology of Achill’s tendon and tarsus and metatarsus.

PNST if at the distal part of peripheral nerves can be treated with good outcome. The reasons are fewer functions that lead in less of dysfunction of the limb, and good surgical margins. If PNST is localized at plexus or nerve root, 78% of dogs are going to be euthanized. The prognosis depends on localization and histopathology grading.