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MVD TEER procedure

PRC

Member
Has anyone considered or had the TEER (transcatheter Edge-to-Edge Valve repair) procedure done for MVD? I'm in the US and there are two Universities (each 10 hours drive away) who are doing this V-clamp TEER procedure for mitral regurgitation. It's relatively new and the Univ have been doing for only 1-3 years. They will not accept any dogs until late B2 or early C stage and must be referred by a certified Cardiologist. The approx cost is $17K-19K if no complications. They indicated due to high demand they are scheduling several months out.
My Bailey is not yet at late B2 and I'm hoping to find someone who has already been there, done that and if they feel it benefited their Cavalier and for how long.
If anyone has additional info please respond or send me a message.
 
Hi and welcome! I've put that question out to some cavalier contacts to see if anyone in my extended circle knows more about this.
 
From a Cavalier friend, Emma Bennett:
This is the surgery our Clemmie had. First in the uk where the US team flew over to do the surgery. She had surgery in May 2022.
After the op her heart size decreased and since then on her 6 monthly checks all measurements have remained the same so it’s not got any worse.
Clemmie is still on vetmedin 2.5mg morn & eve. Although I assumed if the surgery was a success she wouldn’t need vetmedin anymore , the team explained and said as she had been in stage B2 for quite some time her heart muscle was used to being enlarged. The vetmedin is just to support it.
Clemmie is approx 12/13 years of age (rescue unsure of exact age).
The recovery for this op is brilliant she was back home the following day and her normal self. She had a large wound on her side.
 

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I have heard that Vetmedin has continued to be prescribed in aftercare following surgeries such as this one, but I've never heard the reason for doing so. It makes as much sense as any other reason I can think of. It is interesting to realize that once the heart has enlarged, it may not fully recover to normal size following surgery, and even become reliant upon pimobendan (Vetmedin) for the remainder of the dog's life.

I'd like to know at which UK facility this surgery was performed and which USA team was involved.
 
From a Cavalier friend, Emma Bennett:
This is the surgery our Clemmie had. First in the uk where the US team flew over to do the surgery. She had surgery in May 2022.
After the op her heart size decreased and since then on her 6 monthly checks all measurements have remained the same so it’s not got any worse.
Clemmie is still on vetmedin 2.5mg morn & eve. Although I assumed if the surgery was a success she wouldn’t need vetmedin anymore , the team explained and said as she had been in stage B2 for quite some time her heart muscle was used to being enlarged. The vetmedin is just to support it.
Clemmie is approx 12/13 years of age (rescue unsure of exact age).
The recovery for this op is brilliant she was back home the following day and her normal self. She had a large wound on her side.
Thank you so very much!
Bailey is only 8 and the cardiologist & I disagree on stage of MVD, she says still B1 and I think she is B2. She was diagnosed at 6 years by a radiologist who did an echo and 6 mos later when I took her to the Cardiologist her heart had already started to enlarge. A year later at 7 her echo showed as much as 20% larger measurements from the prior echo and regurgitation went from mild to 30%. I assumed the TEER procedure would only manage the regurgitation and didn't know it would help reduce heart size. Bailey is not yet on pimobendan although the same Cardiologist who said she is B1 was willing to prescribe it.
Thank you for the photo of the surgery scar. The literature they sent me says a small 2" incision so I would have been horrified seeing it that large but so happy to hear the recovery went so well.
I don't know if Emma Bennett will see this thread but I would also like to know who the US team was. I'm in South Dakota and we don't even have a Cardiologist in the state so I take Bailey to Iowa State Univ for the echo's. The two Universities that are closest to me are Colorado State Univ who indicated they have been doing the procedure for over 2.5 years and University of Illinois whom I think has only been doing it 1 year. Since these two are already a 10 hour drive for me I did not look further out for others in the US but would suspect they are also done in California and Florida.

I don't understand why they make you wait so long to late B2 with 50% or more regurgitation especially since they list the conditions for favorable/unfavorable outcomes.

Again thanks to all of you who went to great lengths to provide this invaluable information.
 
Thank you so very much!
Bailey is only 8 and the cardiologist & I disagree on stage of MVD, she says still B1 and I think she is B2. She was diagnosed at 6 years by a radiologist who did an echo and 6 mos later when I took her to the Cardiologist her heart had already started to enlarge. A year later at 7 her echo showed as much as 20% larger measurements from the prior echo and regurgitation went from mild to 30%. I assumed the TEER procedure would only manage the regurgitation and didn't know it would help reduce heart size. Bailey is not yet on pimobendan although the same Cardiologist who said she is B1 was willing to prescribe it.
Thank you for the photo of the surgery scar. The literature they sent me says a small 2" incision so I would have been horrified seeing it that large but so happy to hear the recovery went so well.
I don't know if Emma Bennett will see this thread but I would also like to know who the US team was. I'm in South Dakota and we don't even have a Cardiologist in the state so I take Bailey to Iowa State Univ for the echo's. The two Universities that are closest to me are Colorado State Univ who indicated they have been doing the procedure for over 2.5 years and University of Illinois whom I think has only been doing it 1 year. Since these two are already a 10 hour drive for me I did not look further out for others in the US but would suspect they are also done in California and Florida.

I don't understand why they make you wait so long to late B2 with 50% or more regurgitation especially since they list the conditions for favorable/unfavorable outcomes.

Again thanks to all of you who went to great lengths to provide this invaluable information.
 
Hi, PRC. I think TEER in the USA is a little too risky at this point. A guy with details is Nat Estes. He operates a Facebook group page called Mighty Hearts MVD Community, and a website, Mighty Hearts Project. I suggest that you contact him about the TEER surgeries in the USA and what he has heard about the success rate thus far.

You make an interesting observation about whether your dog is in Stage B2 or not. As far as I know, there is no rule that Stage B2 requires that the regurgitation be 50+%. The 2019 ACVIM Consensus Statement (the current one) defines Stage B2 as:

• murmur intensity ≥3/6;
• echocardiographic LA:Ao ratio in the right-sided short axis view in early diastole ≥1.6;
• left ventricular internal diameter in diastole, normalized for body weight (LVIDDN) ≥1.7;
• breed-adjusted radiographic vertebral heart size (VHS) > 10.5.


It says nothing specific about a minimum regurgitation percentage. A high percentage would indicate a rapid progression, most likely, but that has nothing to do with when to start pimobendan, which is what the definition of Stage B2 is all about. That said, I would not start my MVD-affected dog(s) on pimo unless the enlargement is in the moderate to severe category. Those categories are mild, moderate, severe, much like the regurgitation categories of minimal, mild, moderate, severe.

The Florida program is just getting started, but it is not TEER. It is open heart. The California program at the VCA West Los Angeles Animal Hospital is a bit different, It is left atrial decompression surgery, which is intended to relieve the pressure inside the left atrium to reduce its enlargement.
 
Thank you for the reply. I am familiar with Mighty Hearts Project but there is nothing at all on their own website about TEER and I am not on Facebook but from what I could tell, there wasn't anything there either. Not sure why they would say the the TEER in US is not safe because this is where it originated. Colorado State Univ did the initial trial with the manufacturer to test the new V-clamp about 3 years ago and is the one going to the other Univ and training them. I suspect they are the people who traveled to the UK. Colorado State Univ indicated they have not lost any dogs to the procedure but there were 3 dogs who had complications and I believe it had to redone on one, but again all the dogs survived. I was aware that Univ Florida started the open heart repair surgery in August (first time ever available in the US) but the cost is still $50,000 which is a little beyond my reach.

As far as the ACVIM they unfortunately adopted that from the bogus EPIC (Vetmedin) trial and I already told the Cardiologist I refuse to use their bogus numbers that one size fits all breeds of dogs. They killed 15 dogs (8.5%) and said it was insignificant. Common sense alone says that a Chihuahua doesn't have the same size heart as a Great Dane. A small breed will likely be long dead from CHF long before it gets anywhere near 1.6 LA/AO ratio, if ever. Cavaliers have been in CHF as low as 1.3 but the ACVIM would still show them as B1.
Cavalierhealth.org keeps mentioning not to start pimobenden until "significant" enlargement but I need to know what they consider significant. Bailey will have another echo in June and I'm going to contact Cavalier Health and try to get at least what % of enlargement and/or regurgitation they consider significant to start pimobendan. I was hoping someone here already knew that answer.

Beyond all this, there is additional hope for our wonderful Cavaliers. Tufts Univ in Massachusetts should be nearing the end of the 2+ year long trial on gene therapy for MVD. The American Cavalier Kennel Club donated $200k for the trial so the 1st six months they only recruited Cavaliers then opened it to all breeds in stage B2. The manufacturer of the gene drugs did an initial safety trial with 20 dogs, mostly Cavaliers and the results were very promicing that it stops the progression (along with pimobendan) and even reversed the level of MVD in a few dogs. It is totally non invasive only one injection. Keep an eye out for the final results.

I tried to attach a photo of my beautiful Blenheim, Bailey girl. But it keeps saying my pic file is too large to attach.
 
I tried to attach a photo of my beautiful Blenheim, Bailey girl. But it keeps saying my pic file is too large to attach.
There is a size limit, because of my hosting budget. :) If you save the photo to a smaller memory size (not the image size in measurements, but the size in KB or MB) then it should be attachable. Off hand I can't remember the size! This used to be easier when everyone posted online photos to Flickr or other photo hosting sites and so people just posted a link to the photo which then was mirrored here. Those days are long gone though! I need to look at the board software and see if I can find a way to manage this better, perhaps to have a 1 or 2 year life for photos online here after which they automatically delete.

On the gene therapy -- this is an interesting development! And potentially good news for individual dogs if people can afford the procedure. But I keep thinking the original and lasting 'gene therapy' would be if breeders actually followed all the advice of their own club cardiologists and researchers and followed MVD testing and breeding protocols to begin to limit and remove MVD genes from the breed. It's easy to see from club litter registrations just how often the national club breeders breed dogs well under MVD breeding guidelines, sometimes as soon as they hit 12-18 months when they cannot be meaningfully tested and graded for murmurs. And then claim the problem is backyard breeders outside the official clubs. Twenty years I've watched this remain unchanged. :( The official 'ethics guidelines' for the ACKCSC indicate dogs may be bred from 18 months. Still, in 2024. When all evidence points to this being at least a year too early. No wonder our cavalier still lost all die from MVD.
 
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Thank you for the reply. I am familiar with Mighty Hearts Project but there is nothing at all on their own website about TEER and I am not on Facebook but from what I could tell, there wasn't anything there either. Not sure why they would say the the TEER in US is not safe because this is where it originated. Colorado State Univ did the initial trial with the manufacturer to test the new V-clamp about 3 years ago and is the one going to the other Univ and training them. I suspect they are the people who traveled to the UK. Colorado State Univ indicated they have not lost any dogs to the procedure but there were 3 dogs who had complications and I believe it had to redone on one, but again all the dogs survived. I was aware that Univ Florida started the open heart repair surgery in August (first time ever available in the US) but the cost is still $50,000 which is a little beyond my reach.

As far as the ACVIM they unfortunately adopted that from the bogus EPIC (Vetmedin) trial and I already told the Cardiologist I refuse to use their bogus numbers that one size fits all breeds of dogs. They killed 15 dogs (8.5%) and said it was insignificant. Common sense alone says that a Chihuahua doesn't have the same size heart as a Great Dane. A small breed will likely be long dead from CHF long before it gets anywhere near 1.6 LA/AO ratio, if ever. Cavaliers have been in CHF as low as 1.3 but the ACVIM would still show them as B1.
Cavalierhealth.org keeps mentioning not to start pimobenden until "significant" enlargement but I need to know what they consider significant. Bailey will have another echo in June and I'm going to contact Cavalier Health and try to get at least what % of enlargement and/or regurgitation they consider significant to start pimobendan. I was hoping someone here already knew that answer.

Beyond all this, there is additional hope for our wonderful Cavaliers. Tufts Univ in Massachusetts should be nearing the end of the 2+ year long trial on gene therapy for MVD. The American Cavalier Kennel Club donated $200k for the trial so the 1st six months they only recruited Cavaliers then opened it to all breeds in stage B2. The manufacturer of the gene drugs did an initial safety trial with 20 dogs, mostly Cavaliers and the results were very promicing that it stops the progression (along with pimobendan) and even reversed the level of MVD in a few dogs. It is totally non invasive only one injection. Keep an eye out for the final results.

I tried to attach a photo of my beautiful Blenheim, Bailey girl. But it keeps saying my pic file is too large to attach.
As far as I know, that Tufts research has been shut down -- an absolute failure. Interestingly, CavalierHealth.org predicted this failure back in 2017. See https://cavalierhealth.org/blog.htm#June_17,_2017 ("American Cavalier King Charles Spaniel Club’s Charitable Trust falls for the impossible promised dream").

As for what is "significant" enlargement, this is what CavalierHealth.org means by that:

First of all, you have to know what your dog's normal-sized left atrium and/or left ventricle was before the onset of any enlargement. The left atrium (LA) is measured by echocardiogram both as a linear dimension of its width, taken at a specific point in the heart beat cycle (called the left atrium dimension -- LAD) and as a ratio of the LAD and the Aorta dimension (Ao). This is called the LA:Ao or the LA/Ao ratio, and it is used most often by cardiologists when deciding if the left atrium is or is not enlarged.

The left ventricle dimension is measured both using the linear width at a precise point in the cycle and also with this complex calculation called the LVIDdN, which involves both the weight of the dog and an exponent.

Enlargement also can be determined by x-rays. If you compare an x-ray of the heart taken when you know there was no enlargement (a "baseline"), and you compare it to an x-ray taken when you know there has been some enlargement, you can compare the sizes of the heart using a method called the Vertebral Heart Size (VHS).

As an example using the echo measurement of the left atrium (LA), let us say that the LA:Ao ratio when the dog had a normal sized heart was 1.1. This would be typical for a cavalier, which as a breed has a range of normal LA:Ao ratios from around 0.47 to 1.36. That is a wide range for one breed, which shows how unhelpful it is to rely upon even a breed-specific reference range when you are trying to figure out what it is for just one cavalier.

So, if the dog's normal LA was an LA:Ao of 1.1, and then a year or so later, after the dog has been diagnosed with a mitral murmur, the next echo scan showed a LA:Ao of 1.25, that tells you that the left atrium has begun to enlarge. But, is it "significant enlargement"? Probably not. I would not start pimobendan at that point, even though we know that enlargement has begun. Why not?

Well, there are at least a couple of reasons. First, we know from published research that pimobendan can cause some bad "adverse reactions" in some dogs, and especially when the drug is given to dogs with healthy hearts or too soon in the enlargement cycle. Those adverse reactions have been known to include acceleration of the MVD's progression, and even sudden death. As you pointed out, in the EPIC Study, 8.5% of the dogs in the pimobendan group (as opposed to the placebo group) died of sudden cardiac arrest before any of them reached heart failure.

Another reason for waiting to start the pimobendan is a lesson in the EPIC Study itself. About 45% of all of the dogs in the EPIC Study were cavaliers. It is unfortunate that the investigators have refused to single out the CKCS data in that EPIC Study and report on our breed alone. I asked Dr. Boswood, the lead investigator in EPIC, to do that, and he told me no. Suffice it to say he can be a real jerk.

So what do we learn from the EPIC Study about when to start pimobendan? Well, before they started to accumulate their data from the dogs in that study, those investigators arbitrarily defined an enlarged left atrium as having a LA:Ao ratio of 1,6 or higher. (I say "arbitrarily" because none of that definition was based upon any published evidence of cut-offs between normal and enlarged on a species-wide basis., and at least 31 published articles have insisted that at the very least, breed-specific cut-offs should be used when determining if a dog has an enlarged heart or not.)

What this meant in so far as the cavaliers in the study were concerned is that they all had not only enlarged left atria, but they had significantly enlarged left atria. The cut off for normal sized left atria in CKCSs is about 1.36, and 1.6 is significantly larger than that.

Now, one thing Dr. Boswood told me about the 8.5% of dogs in the pimobendan group that died of cardiac arrest is that 4% (or half) were cavaliers. We don't know why they died, because the investigators refused to do post-mortems on any of them, but we know from prior research that some dogs reacted very badly to pimobendan when started too early. Also, I spoke with another cardiologist who was one of the investigators in the EPIC Study about those dead dogs. This guy is probably the top veterinary cardiologist in the world. Dr. Boswood pales before him. This cardiologlist (who shall remain un-named) said they probably died of atrial fibrillation, very likely due to the effects of the drug. He said that because of the suddeness of their deaths.

So, my bottom line for defining "significant enlargement" is, in the context of the left atrium (leaving the left ventricle and the Vertebral Heart Size -- VHS for another day), for a cavalier with a normal LA:Ao of 1.1, a significantly enlarged LA:Ao in the range of 1.6 and certainly not as low as 1.25.

 
As far as I know, that Tufts research has been shut down -- an absolute failure. Interestingly, CavalierHealth.org predicted this failure back in 2017. See https://cavalierhealth.org/blog.htm#June_17,_2017 ("American Cavalier King Charles Spaniel Club’s Charitable Trust falls for the impossible promised dream").

As for what is "significant" enlargement, this is what CavalierHealth.org means by that:

First of all, you have to know what your dog's normal-sized left atrium and/or left ventricle was before the onset of any enlargement. The left atrium (LA) is measured by echocardiogram both as a linear dimension of its width, taken at a specific point in the heart beat cycle (called the left atrium dimension -- LAD) and as a ratio of the LAD and the Aorta dimension (Ao). This is called the LA:Ao or the LA/Ao ratio, and it is used most often by cardiologists when deciding if the left atrium is or is not enlarged.

The left ventricle dimension is measured both using the linear width at a precise point in the cycle and also with this complex calculation called the LVIDdN, which involves both the weight of the dog and an exponent.

Enlargement also can be determined by x-rays. If you compare an x-ray of the heart taken when you know there was no enlargement (a "baseline"), and you compare it to an x-ray taken when you know there has been some enlargement, you can compare the sizes of the heart using a method called the Vertebral Heart Size (VHS).

As an example using the echo measurement of the left atrium (LA), let us say that the LA:Ao ratio when the dog had a normal sized heart was 1.1. This would be typical for a cavalier, which as a breed has a range of normal LA:Ao ratios from around 0.47 to 1.36. That is a wide range for one breed, which shows how unhelpful it is to rely upon even a breed-specific reference range when you are trying to figure out what it is for just one cavalier.

So, if the dog's normal LA was an LA:Ao of 1.1, and then a year or so later, after the dog has been diagnosed with a mitral murmur, the next echo scan showed a LA:Ao of 1.25, that tells you that the left atrium has begun to enlarge. But, is it "significant enlargement"? Probably not. I would not start pimobendan at that point, even though we know that enlargement has begun. Why not?

Well, there are at least a couple of reasons. First, we know from published research that pimobendan can cause some bad "adverse reactions" in some dogs, and especially when the drug is given to dogs with healthy hearts or too soon in the enlargement cycle. Those adverse reactions have been known to include acceleration of the MVD's progression, and even sudden death. As you pointed out, in the EPIC Study, 8.5% of the dogs in the pimobendan group (as opposed to the placebo group) died of sudden cardiac arrest before any of them reached heart failure.

Another reason for waiting to start the pimobendan is a lesson in the EPIC Study itself. About 45% of all of the dogs in the EPIC Study were cavaliers. It is unfortunate that the investigators have refused to single out the CKCS data in that EPIC Study and report on our breed alone. I asked Dr. Boswood, the lead investigator in EPIC, to do that, and he told me no. Suffice it to say he can be a real jerk.

So what do we learn from the EPIC Study about when to start pimobendan? Well, before they started to accumulate their data from the dogs in that study, those investigators arbitrarily defined an enlarged left atrium as having a LA:Ao ratio of 1,6 or higher. (I say "arbitrarily" because none of that definition was based upon any published evidence of cut-offs between normal and enlarged on a species-wide basis., and at least 31 published articles have insisted that at the very least, breed-specific cut-offs should be used when determining if a dog has an enlarged heart or not.)

What this meant in so far as the cavaliers in the study were concerned is that they all had not only enlarged left atria, but they had significantly enlarged left atria. The cut off for normal sized left atria in CKCSs is about 1.36, and 1.6 is significantly larger than that.

Now, one thing Dr. Boswood told me about the 8.5% of dogs in the pimobendan group that died of cardiac arrest is that 4% (or half) were cavaliers. We don't know why they died, because the investigators refused to do post-mortems on any of them, but we know from prior research that some dogs reacted very badly to pimobendan when started too early. Also, I spoke with another cardiologist who was one of the investigators in the EPIC Study about those dead dogs. This guy is probably the top veterinary cardiologist in the world. Dr. Boswood pales before him. This cardiologlist (who shall remain un-named) said they probably died of atrial fibrillation, very likely due to the effects of the drug. He said that because of the suddeness of their deaths.

So, my bottom line for defining "significant enlargement" is, in the context of the left atrium (leaving the left ventricle and the Vertebral Heart Size -- VHS for another day), for a cavalier with a normal LA:Ao of 1.1, a significantly enlarged LA:Ao in the range of 1.6 and certainly not as low as 1.25.

Thank you, sorry I just saw your message now.
Thank you for the link to CavalierHealth Tufts info. I had just today noticed the trial was suspended. I had been so hopeful after reading positive results from their test trial. I never saw it on Cavalierhealth at all. I hate that they don't have key word search as I read page after page looking for something only to get side tracked by something else.

I did also visit Mighty Hearts website and it looks like nothing has been updated in over a year. I emailed them from their website in reference to TEER but the email bounced. Possibly now that the open heart surgery is available in US, they no longer need to help with international travel for open heart surgery?

Thanks for trying to explain significant enlargement to me. Just so happens that the LA:AO of 1.1 in your example is exactly what the first reading is for Bailey although she already had a grade 2 or 3 murmur at that point. I did indeed think that 1.25 or 1.3 would be a significant increase. This is good news in that two years after that initial diagnosis she does not need pimobendan. I don't remember why but I thought 50%MR also meant to start pimobendan regardless of LA:AO ratio but maybe I'm confusing the MR with the requirements to do the TEER procedure.
 
Hi all!

Our Chloe is a 6.5 y/o Black and Tan that has been staged in that dreaded B1/B2 area. Her numbers are below:

2021:
LVIDd: 3.15 cm
LVIDdN: 1.7
LA/Ao: 1.34
LA diam: 2.21 cm
Ao diam: 1.65 cm
%FS: 33.6%

2023:
LVIDd: 3.15 cm
LVIDdN: 1.65
LA/Ao: 1.05
LA diam: 2.41 cm
Ao diam: 2.3 cm
%FS: 44.7%

Our cardiologist in Kansas deemed her in 2023 to have "equivocal" enlargement and due to the grade of her murmur (4/6) and severe regurgitation, we did start pimobendan. We have follow up in a week. She is asymptomatic.

What are anyone's thoughts about the numbers? I particularly questioned the increase in Ao diameter (specifically because that larger number compared to 2021 is why her LA/Ao is smaller), and he attributed it to differences in technique/inter-individual variability with the user. He said the numbers this year will be useful because the same person is doing the procedure (him).

Interested to learn about what people here think, and if I should be pushing to talk to folks regarding TEER.

Thanks.
 
Hi,
Sorry to hear another Cavalier joins this club. I think you may need a second opinion from another cardiologist as I tried to compare Chloe's numbers with Bailey's and can't make sense of it. Iowa state gives me more detailed list of measurements than I need and it gets confusing, IE: Bailey's LA (maximum end systole) is 2.77 , grade 4 murmur, FS 35.8, regurgitation 30%(moderate) but there are several different Ao measurements and not sure which one would compare to Chloe. Bailey is a stage B1 asymptomatic on her last visit 10/2023 but we have another June 25th. How did Chloe's FS go back to normal range?
I hope Chloe is tolerating the pimobendan well and that you'll continue to post on this site. It's scary when you don't know others going through the same thing.

Best wishes,
Pat
 
Hi,
Sorry to hear another Cavalier joins this club. I think you may need a second opinion from another cardiologist as I tried to compare Chloe's numbers with Bailey's and can't make sense of it. Iowa state gives me more detailed list of measurements than I need and it gets confusing, IE: Bailey's LA (maximum end systole) is 2.77 , grade 4 murmur, FS 35.8, regurgitation 30%(moderate) but there are several different Ao measurements and not sure which one would compare to Chloe. Bailey is a stage B1 asymptomatic on her last visit 10/2023 but we have another June 25th. How did Chloe's FS go back to normal range?
I hope Chloe is tolerating the pimobendan well and that you'll continue to post on this site. It's scary when you don't know others going through the same thing.

Best wishes,
Pat
Thanks for the reply. I have more numbers, but the ones included in my post were because that's what I've seen in the literature. I have some background in Cardiology (humans), but there are enough differences that I feel uneasy. She has her next visit this week, and I'm assuming we will do another 2D echo.

Chloe is actually tolerating the pimo very well. Her stool has been softer since starting in 6/2023, but that's all I noticed. Her vitals including her resting respiratory rate have remained unchanged since her murmur was first discovered in 2019 when she was just over a year old. Her murmur worsened from a Grade 3 to Grade 4 over 2022 - 2023, but has remained the same since starting pimo (our general vet even said she might be a little less impacted). She is still very active and I can't identify anything that would suggest she's progressing.

I will say that I was initially worried about starting pimo on Chloe, and that was primarily due to having knowledge about the indications of similar drugs in humans (eg milrinone is used as a continuous infusion to provide inotropic and contractility support in humans as they await a heart transplant in refractory heart failure cases). Also, there were human studies with pimobendan or other meds in the class and there was harm demonstrated. I was led to believe, and still do more or less, that most dogs probably do tolerate pimo quite well, and I would be able to tell if she had a conduction disturbance like a-fib (I auscultate her once a week after my cardiologist showed me how).
 
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