Questioning valve repair surgery

Hi. i haven't posted on here in a very long time, mainly because of a health problem i had, undiagnosed, crazy making, finally diagnosed after 8 years, it started the year i got Zack my dog, 2006, but i didn't know it until 2014, it was serious and debilitating in a fluctuating way, but fortunately curable, diagnosed in 2014, it was an insulinoma tumor on my pancreas, very rare, 4 per million per year, but once you know you have it, you get surgery and it's cured usually, only less than 10 percent are malignant. i'm cured. But for 8 years the tumor depleted the glucose from my brain and it got so hard to function and i didn't know why. The glucose was so low that when i had blood tests, they always thought it was a lab error because when it's that low, you're not supposed to be up walking around. but i didn't know there was anything medically wrong with me and i didn't question that i had to go to work. That's why i retired early, i couldn't do my job anymore (public child welfare). i just thought i was inexplicably tired and no longer able to handle stress like i used to, my judgement was very weird, some character defect or something. The brain needs glucose, i have sense learned all about this.

I am here because Zack is 11 1/2 now, he has been very well fortunately, no health problems--except MVD. Murmur was first heard in 2014 when he was 9, grade 3, he had cardio work up then, mild heart enlargement, mild to moderate regurgitation. He also had a chronic dry occasional short (3 seconds) cough, the cardiologist said he saw no reason that it would be related to the heart. Zack felt very well and so no medication. The cardiologist has a cavalier at home.

It's been two years, the cough continues, i took him back for another cardio evaluation last month. Now, heart enlargement is moderate, regurgitation is severe. Still appears to feel well, normal, no exercise intolerance, breathing while asleep is 15-25, consistently. The cardiologist told me about the EPIC study and said because of it, he is recommending pimobendan. He explained why. If not for the EPIC study he would not be recommending medication yet, but check him again in 6 months.

I told him i will read up in pimobendan before deciding. I read what there is on Cavalier Health, the commentary which raises concerns about the 12% or so of dogs whose MVD was worsened by pimobendan. The researchers didn't consider this to outweigh the benefits. Cavalier Health commentary noted that the study was totally funded by the pharmaceutical company that makes pimobendan. The concern they express which i of course share is that researchers did not look at the specific characteristics of those dogs that were worsened by the medication, some or all of those dogs died sudden cardiac death due to cordae rupture, from the increased contracting of the heart caused by the medication. The commenter pointed out that a third of the dogs in the study were Cavaliers, and wanted to know more about which dogs died and if it had any relation to breed. me too. So i'm still considering pimobendan. i have a dog who feels good, enjoys his life and doesn't know he's sick so i need to know what the reality of it is and think it through.

I read most of what is on the Cavalier Vet Info page which summarizes all the research on pimobendan since 1989. The adverse effects from increased contractility were noted all along and only if CHF was diagnosed was it recommended to give dogs with MVD pimobendan, until the EPIC study published last September, which caused a change in the recommendation because the medication was now thought to delay onset of CHF. No doubt a lot more dogs will be taking it now, so more will be learned in clinical practice.

So now i have to think about this and learn about statistics about cavaliers who have MVD, what their life expectancy is, i know that there is a wide range of difference in what age dogs become symptomatic and how they are affected by it. i want to learn more about that. i wonder what the statistics are on dogs with MVD/CHF who don't have any treatment, any medication. i don't know if this information is out there.

Zack's lifelong health insurance plan that he had, which was pretty affordable, has just been sold to a different underwriter and the cost of it is going to go up, the whole thing is being restructured. I have a decision to make about that. i have to choose one of their new plans. I am looking at two choices. One is $10,000 a year coverage. The premium is $148 a month, with a $250 a year deductible. The main thing that hurts me is the copayment. My other plan didn't have any copayment. The copayment is 20%. but i am stuck with this company because no other company will cover his pre-existing condition. So, my other choice is $5000 a year, $250 deductible, 20% copayment, $118 a month premium. The difference between $118/month and $148/month is a lot, it's not like the pay check stretches that far.

I am not very clear about the costs of treatment for MVD, once Zack goes on medication of any kind, or various kinds, but i'm guessing it would not be more than $5000 a year. i know there can be things like emergency vet treatment and inpatient treatment, those things can add up fast. But the main reason i can think of to buy the $10,000 a year plan would be if valve repair heart surgery would be a possibility for him. i need to learn about how much that costs, probably more than $10,000? I am wondering if anyone knows anything about this surgery, or where to look for information about it.

I have to make this decision pretty quick because the insurance company gave me until March 18 to tell them which plan i want. His old plan will end on his renewal date which is March 31.

I will ask his cardiologist, or the assistant, whoever i can get in touch with, but i would like to get a range of opinion, not just one opinion.

Has anyone here had valve repair surgery for their dog, or is anyone thinking about it? Zack also has tricuspid valve dysfunction in addition to mitral valve, but the tricuspid is mild.

When Leo was diagnosed with MVD my cardio vet discussed the options. At the time (3-4years ago) I was told that valve replacement surgery wasn't an option as it wasn't carried out in dogs or wasn't successful I cant remember which just that it couldn't be done.
Leo was started on meds and was given another 2 years of good quality life.....His little heart finally gave out in October 2015.

I know each dog is different but Leo did well and I was grateful for the extra quality time I had with him.

Good luck with what ever you decide for Zack.

Mel

Hi Judy!

Only very few valve repairs have been carried out worldwide, and I wouldn't think any insurer would cover it, especially as an option to standard meds for a dog over 11. It is still considered experimental. I only know of one place in UK doing it for example, and they've only done 8 dogs. Not sure of success rate.

Meds shouldn't be more that around 100 a month at most, I would think.

I wonder has your cardio considered whether he has a soft esophagus? One of mine that has no other problems has this; the enlarged heart presses on it. Even though she otherwise would not be on meds, she takes low dose pimobendan and that has really helped the cough and made her far more comfortable. She is around 11.

My Jaspar passed away in August at just shy of 13 -- otherwise so fit -- due to MVD. Given the results of the pimobendan study I believe he would have benefitted and had many more months if he'd been put on it. The results indicate a dog for which this is indicated (and not all are) can get months to well over a year before going into CHF. I am sorry the study wasn't completed a bit earlier.

As you will know already, 11 1/2 is a good age for a cavalier generally, given their heart issues do take away from overall life expectancy. I think you'd probably want to ask these questions to your cardiologist as to options. I believe most likely he would recommend medications.

On the insurance options -- 20% copay is actually very low for a dog this age. Many policies expect 50% copay for a dog over 8 or 9. I'd definitely go for the lower cost one though given options. If I had a dog with MVD that needed emergency treatments that might run above 5,000 in a year my own feeling is, I'd be questioning whether the treatments were really for the benefit of my dog, or more for me... with MVD, I think there's just a time when it is best to make that hard but loving decision so they do not suffer. I've been fortunate in that my dogs with MVD have all gone gently but one did have many ups and downs with fainting episodes etc and it could be very distressing. I truly hate MVD and have found it more difficult and distressing to manage than SM, especially because too often the dogs have been otherwise quite happy and heathy and should have lived many years longer.

Let us know what your cardio says and what you decide. We were only just discussing the valve surgery here today (a friend was over) and wondering what the results were for it. If it had been a viable option I'd have paid for it in a nanosecond for Jaspar so can understand the debate about it. It is certainly not anything like a standard procedure or even available in most places in the world. I suppose you'd be weighing up the possibility of losing him to the surgery itself, if it is available, vs gaining possibly up to a couple of years with meds.

Hi Karlin!

thank you for all that info and your experience. I am sorry to hear about Jaspar. sorry about all of them, each and every one, but Jaspar....i remember him best, his personality, from your tales of his antics.

You provided information that is what i need to get it in perspective. All i know is what i remember from some years ago when i spent a lot of time here, and many were going through this and the surgery was discussed, and i did a little research, they do it that surgery at UC Davis, which is in my state at least, but really far, but i have no recent info, and maybe it was valve replacement back then. For humans, repair is increasingly done.

The main thing i remember from back in 2007 or so, was one of our members here who lives in California having the surgery done on one of her two or three Cavaliers, and she posted either photos or videos of her dogs running on the beach together, near San Diego, to show how well her boy had done with the surgery. That imagery stayed with me.

Also though i remember reading on the UC Davis website, or somewhere like that, (i remember they also do it in Colorado, and they do a small number of dogs a year, at least if my memory is right, it might not be, 2 or 3 dogs, and also there was a place in Texas), i remember cautions about the surgery, that not all dogs will do well and it can be very hard on some, and aftercare can be difficult. i don't want to risk putting him through that.

My cardio guy didn't mention soft esophagus. i will ask him and will google it. Is pimobendan thought to reduce cardiomegaly some? For all the reading i did about it 3 or 4 weeks ago, i don't remember what the benefits were, other than statistically being associated with months to a year and a half longer life (or onset of CHF?). About the cough, the doc just said 'pressing on the airways.' It must give a sensation of some kind of irritation or obstruction, poor babies.

When i was reading through Cavalier Health Vet Info page to read about research into pimobendan, in the course of that, a report summary caught my eye about a vet using a homeopathic remedy to treat a cardiac associated cough--one dog was discussed in the excerpt from her report in the journal. it's from a holistic vet journal, New Zealand. Here's an excerpt, reported July 2014:
"....Case Examples: Ellie, a 10-year-old Cavalier King Charles Spaniel with cardiac cough due to mitral valve disease: Ellie was on all the usual medications to control her mitral valve disease including diuretics, but her cough remained. It was thought that the cough was caused by an enlarged atrium physically pressing against the thoracic trachea. Her cough was dry and non-productive and on questioning I discovered that the cough improved after eating. On this basis I prescribed Spongia 30c once per day. On followup the cough was noticeably improved....It is worth considering homeopathic remedies as an additional support for cardiac disease in situations where conventional medicine is either unaffordable or is failing to control the symptoms adequately. Of course the results will be dictated by how advanced the disease is and we need to be realistic when discussing the options with our clients. The remedies can be used safely on their own, though I would recommend using them in conjunction with conventional medication."

I figured there was nothing to lose so i went out and got Spongia 30c and gave it to Zack as directed on the container. I'll be darned if his cough didn't decrease in frequency, dramatically, within the first hours he was on it. ?? Probably coincidence? Before that, on rare occasions, he would have better days with the cough, less coughing, maybe once a month. i kept giving it to him, and there is no doubt, for however long it's been, 2-3 weeks, it's not the same cough. it sounds just as bad, awful, he struggles with it so, but instead of throughout the day fairly often, at least every hour, it's now many hours, 6, 8, 10 hours between each cough. I feel confident that it's related to the remedy, although i don't know why, it makes no sense that such a thing would work, but combining the report of the vet (her name is Wendy Dixon) with this experience of dramatic change in the frequency of the cough shortly after starting the remedy, i feel confident that the spongia is the cause of the improvement, leaving open that it may be caused by something else, but i have no guess what else it would be, it never happened before, except with prednisone. Either way, i'm not confident that the cough won't come back, i know it may get worse again. it's just a very cool thing that has happened, much less stress from the sound of that cough in the past two or three weeks. i never would have known to try Spongia if i hadn't been reading up on pimobendan.

I'm encouraged by hearing about your experience that low dose pimobendan appears to have helped your girl, her condition and her time. This touches on one of my hesitations. Can you say what a low dose of pimobendan is, milligrams? That was something i was hesitating about, i wanted to start at a low dose, and if needed, increase, but the prescription discussed was the standard dose, i think. Maybe it's a low dose---he recommended 2.5mg two times per day. He also prescribed hydrocodone tablets for the cough, and i got that and brought it home, but so far, the cough isn't persistent enough. It lasts maybe 3 seconds, until the next time.

I appreciate your guess about a general idea about how much meds would cost a year (under $5000). That's what i was thinking. The pimobendan is about $50 every two months, i think he said, but i know there may be other meds too as needed.

Your thinking on what to do when emergency care is needed, i share that. I don't want him to go through that. i know that he would not want that. i know him. If he were symptomatic enough to need that, his quality of life would not be what makes his life with living.

The other expense would be the echocardiogram and chest X-rays, i don't know how often they do that to monitor the progression, to see whether the medication is making a difference and just to see what the situation is--i'm guessing if i have echo and X-rays in 6 months, that will be all for this year. What he had in February was $742. The insurance reimbursed all of it, i was surprised because there is supposed to be a $100 per incident deductible on his old plan, and they didn't take that off, but i'm guessing it has something to do with the new insurance starting and how i will have to pay that $250 deductible once it goes into effect.

I feel kind of better to hear that 20% copay isn't as bad as it could be at Zack's age. I didn't think about that. The copay kind of defeats the purpose that i got the insurance for, which was so that i wouldn't have to think about spending money i don't have when he gets sick, if the bill is going to be large.

The information and experience you've shared has helped to clear up my thinking on the decisions i have to make, treating with pimobendan at this time, and whether to pay for $10,000 a year insurance coverage. The only reason to get the $10,000 coverage would be if valve surgery was a realistic option. Until you mentioned it, i didn't think it would be considered experimental since they've been doing it for a long time now, but i think you're right. And even if it was covered, it's not clear what the suffering would be or the prognosis. I just remember the beautiful video of that one dog, running on the beach after his recovery from the surgery...

I will talk to the cardio vet tomorrow, my remaining questions are clear now, about the pimobendan dosage and about what he knows and thinks about the insurance/surgery option.

i understand what you mean about the cruelty of MVD--i haven't experienced the pain of SM, but know of the terrible suffering, while it's as you say, Zack doesn't know he's sick, he just wants to go on enjoying the things he loves, like galloping into the backyard and barking at squirrels and seriously sniffing everything and putting his nose up into the breeze to check out what's going on in the world smell-wise, or playing by himself with his toys in the living room, rolling on his back with his favorite squeaky in his teeth, playing some kind of imaginary fight game with it, fetching a ball, snuggling, playing tug o war, and he he's a happy healthy dog, who i can see is losing his high energy level, the coughing, the vet's report said to restrict exercise, that hurts. i don't know what Zack feels like, but not bad enough to look depressed. Without MVD, i'm sure he'd live to be late teens, he's never had any health problems, he's led a charmed strong healthy life. I hope there has been progress with breeders since i was last following discussions on that, but i know that that progress is only in the case of reputable breeders and there are many more who don't give it any thought. I'm glad almost all of yours have 'gone gently.' i want to do anything i can to help Zack go gently.

thanks so much.
Judy

Mel - thank you for your reply. I'm sad to hear about your loss of Leo. I'm glad you got more time with him than you otherwise would have. Thank you for sharing your experience, that is what is helpful. Was he on other medication too? When he first went on the medication, were you already seeing some effects of the disease? In Zack's case, i can see he is slowing down a little though i'm not sure if it's paranoia after his cardio eval last month which shows progression since the first one, or a real sign of something. I am leaning toward giving him pimobendan and just want to be as clear as i can that it's the right thing. I'm reassured to hear that your experience is that medication was helpful.
thank you for telling me about your experience
Judy

Hi Judy
Leo was put on Furosemide and cardalis too. I was seeing effects of the disease before he went on meds yes! He was listless and slow and had developed the "cough".
He was on the lowest dose of both until the week before he died. He did so well on the meds, he was like a new boy once they kicked in. He had slowed down but could still walk a fair distance with out struggling and was still his cheerful excited self.
He did slow down over the next year and half but his quality of life was good and no time did I feel he was suffering.
He collapsed very suddenly one Thursday evening. The vet increased his meds but he died very suddenly and (peacefully thank God) early on the Saturday morning.
I know others are not fans of the drug but from my experience it really helped. Had he suffered regardless then it would have been a different story but it most definitely gave him quality.

Its heart breaking to watch and although I miss him terribly I was so thankful for the extra time we had.

Let us know how you get on with Zack.....I'll be thinking of you
:hug:

mel - thank you for your story of Leo, if a dog has to have heart failure, Leo had the best kind to have. What a good feeling to see him improve once the medication was started, to have that much time with him happy and enjoy life, and for his ending to be fast, and free of suffering and the depression that comes with it. And you were spared having to make the painful choice, to choose the time, even knowing it's right. i can only hope it will be like that with Zack.

People are opinionated about the medications, i understand that, the pros and cons, and each dog is different, vets don't even know which dog is going to have what kind of course of the illness, with or without medication, nobody knows. Everyone is motivated by love for their dog and wanting to protect and wanting the best for them.

If valve repair surgery was more available than it is, i would definitely want to consult about it with the people who are doing it. I read that they are working on a minimally invasive approach, but i looked into surgery in the past weeks and found it very difficult to find out anything. I talked to my insurance company and another one that i picked at random on the web, a big one, and neither one could say for sure if it would be covered but the bottom line was that if a vet said it was medically necessary, and wrote it up with convincing evidence, that's what the underwriters go by, that's what my company said, and i asked explicitly about if it was experimental, if it was research. The other company said if it was in conformity to the veterinary standards in my state (it's a nationwide company).

It seems so murky and inaccessible, i can't even get to the stage of having him evaluated for surgery and find out what the risks are. It's not a realistic option.

Anyway, thank you for your thoughts for Zack and me and sharing what it was like for you and Leo.

Hi Judy

You're welcome. You are so right that I was thankfully spared the dreadful decision to have Leo PTS...he spared me that

Good luck with what ever journey you take with Zack. Let us know how you get on....

Best wishes

Mel xx

I apologize for missing the rest of this thread until now. Here is my response to Judy's initial questions about surgery:

Do you have a Facebook account? I ask because there is a Facebook group which has members who either have been through their dogs' surgeries or are planning to do so. The link is https://www.facebook.com/groups/MightyHeartsMVDCommunity/

Here are direct website links to the surgeons, if you do not have a Facebook account:
https://mightyheartsproject.org/
http://www.cliniqueveterinairebozon.fr/
http://www.jasmine-vet.co.jp/English.html
http://www.tierklinik-sattledt.at/

The price tag seems to run over $30,000, and the venues are France or Japan, with a possibly lower price by an Austrian surgeon, Dr. Modler. Here is a link to CavalierHealth.org's discussion on the topic of surgery http://cavalierhealth.org/mitral_valve_disease.htm#Surgery

All of the reported successful surgeries have been open-heart with cardio-pulmonary by--pass, meaning that the heart is stopped and the blood is pumped by an artificial device. Apparently Dr. Uechi's success rate is quite high. As to whether it is worth it, I suggest you communicate directly with the surgeons' offices and tell them your dog's condition and other details. They are the best to judge if Zack would be a good candidate.

Let me know what you decide. Again, I apologize for missing your message until today.